Executive Summary - Fss.aero

Pilot incapacitation on China Airlines Flight Ci681, an A300-600R, B-18503,
on 2000-05-08
Micro-summary: The captain of this airplane was discovered incapacitated during
cruise.
Event Date: 2000-05-08 at 0817 Taiwan time
Investigative Body: Aviation Safety Council (ASC), Taiwan
Investigative Body's Web Site: http://www.asc.gov.tw/
Note: Reprinted by kind permission of the ASC.
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Executive Summary
31 minutes after taking off from Taiwan's CKS International Airport at
0746 Note local time on May 8, 2000, and during cruising level flight and heading
for Ho-chiming City, Vietnam, the first officer of China Airlines' flight CI681, an
A300-600R with registered number B-18503 and carrying 265 passengers found
out that the captain had suddenly showed no response to the flight. Following the
incapacitation procedures, the first officer called the cabin chief flight attendant
and a flight attendant to help him to move the captain to the main cabin (galley) to
do the first aid. At the same time, through the passenger address system the cabin
chief announced for the help of a doctor on board, if any.
Then the first officer decided to turn back to CKS International Airport.
Eventually, the aircraft landed safely via autopilot system on Runway 05-Left. At
0816, before landing, a request was issued for ambulance and towing vehicle to
stand by. The aircraft landed at 0850 and stopped on the taxiway at 0852. As
China Airlines allows no first officer taxi, the aircraft waited to be towed to the
parking bay. After towing to the parking bay, medical personnel embarked the
aircraft to carry out first aid. At 0936, the captain was carried to Mingsheng
Hospital in Tao Yuan County. After unsuccessful operations, the captain was
announced dead at 1020 in that hospital.
This flight crewmember incapacitation incident was rated as a serious
incident and was then investigated by the Aviation Safety Council (ASC), the
Executive Yuan. After the acknowledgement of the incident, ASC dispatched his
investigators, as stipulated in Art. 84 of the Civil Aviation Law, to both CKS
International Airport and China Airlines for investigations that included interview
to associated personnel, examination to the captain's personal flight bag and the
read out of Cockpit Voice Recorder (CVR) of the aircraft.
Note: All times indicated in this report are Taiwan time (Taiwan Time = GMT + 8).
At ASC, an investigation team was then established as stated by "The
Regulation of Accident and Serious Incident Investigation Procedures ". An
investigation was focused on potential causes to the captain's incapacitation and
the emergency responses of the ground to the incident. After the investigation,
ASC had the findings, probable causes and recommendations as below:
i

Findings
1. The captain held a physical certificate and a certificate of the aircraft rating
issued by Civil Aeronautics Administration (CAA). The physical certificate
showed no specific restrictions or any record of waiver. (1.5.1)
2. According to the data of his heavy weight, age, hyper lipidemia and smoking
habit in his physical examination record, the pilot was grouping to a high
potential cardiac patient. (1.13.3,1.13.4)
3. The incapacitated pilot made no remarkable improvement to the suggestions
of the physical examination doctors. (1.13.3).
4. There was no pilot’s medical history dated before his coming to work in
Taiwan.
5. The track cardiograph of the pilot physical examination record showed no
symptoms of myocardial infarct. The Aviation Medical Center did not have
to conduct the follow-ups in accordance with the Procedures of Physical
Examination of CAA. (1.13.5,2.2.6)
6. The pilot’s working hours, flying hours, and Rest time were totally in
accordance with CAA laws. The flight crew who flew with the said pilot in
one or two days before the incident said that he did not exhibit any
irregularity at work. (1.5.2)
7. The medication the captain carried with him showed no toxic ingredients or
any cardiac-healing medicaments. (2.1.1)
8. The cause of death of the pilot was coronary artery occlusion, i.e., a natural
death. (2.1.2)
9. The first officer conducted the flight with autopilot. The weather of the day
was fair and the aircraft was in airworthiness condition. Before the incident,
no flight crew had extra workload and the captain was under regular pressure
of work. (1.1,1.6.2)
10. When the pilot incapacitation happened, the first officer proceeded with the
airlines' incapacitation procedures and landed the aircraft safely with auto-
land system at CKS International Airport. However, the first officer failed to
use emergency phraseology to report the serious incident. (1.1,1.15.2,1.15.6)
11. As the captain experienced the incapacitation, the flight attendants that
entered into the cockpit had good cooperation with one another and kept
performing cardiopulmonary resuscitation (CPR) to the captain. (1.15.3)
12. The doctor on board performed first aid to the captain and found that the
captain had incontinence of urine, mydriasis, no heartbeat and pulse reaction.
(1.15.3)
ii

13. The CKS International Airport provided medical personnel and facilities and
maintained a medical cooperative contract with MinShen Hospital. The CKS
Airport also provided procedures for seriously ill passengers to quickly pass
the immigration. However, there were no medical treatment operation
procedures established in CKS Airport. (1.13)
14. In the "Civil Aircraft Accident Procedure Highlights" of the CKS
International Airport, it stipulated that medical service in airport was the
responsibility of the contracted Mingsheng Hospital. However, the said
Highlights failed to describe the duties and detailed procedures of the medical
service team. (1.13,2.3.10.1)
15. . The air traffic controllers at Taipei Area Control Center failed to understand
the message of incapacitation sent by the first officer of the aircraft. They
relayed a wrong message of a seriously ill passenger to the airport authority.
Again, the first officer made requests twice to land on Runway 05-Left,
however, the air traffic controllers answered runway in use 06. It was
observed that the air traffic controllers failed to comprehend the message sent
by the first officer and that severely affecting the following emergency
operations on ground. (1.15.6, 2.4.1,2.4.5)
16. The airport authority failed to offer the nearest parking bay available for the
emergency response servicing. (2.4.7)
17. CAL's Asian Dispatch Center personnel failed to fully communicate with the
first officer and keep close contact with the CKS International Airport
authority. CAL's Asian Dispatch Center personnel failed to response properly
for saving the time to comply the request of the officer to call towing vehicles
to stand by the runway. It made the aircraft wait for towing vehicles for as
long as 9 minutes (0852-0901) on the runway. (1.15.6, 1.15.6.1, 2.4.3, 2.4.4)
18. The commanding vehicle at the scene had no two-way radio for
communications with the aircraft that made it impossible to know
immediately of those emergency responses such as that the first officer was
not authorized to taxi, the condition of the sick person and the intention of the
aircraft commander. (1.15.6.2,2.3.8)
19. CKS Airport had the “Implementation Highlights of CKS Airport Accident
and Incident Handling Procedure”, the “Civil Aviation Accident Notification
Procedures,” the “CKS Airport Transit Procedure for Emergency Sick
Passengers,” and the” Firefighting Operation Handbook”. However, there
was no such “ Full Emergency Operation Procedures” as recommended by
International Civil Aviation Organization. (1.18.1,2.4.3,2.4.6)
iii

20. The aircraft landed and came to a completely stop at 0852. The incapacitated
pilot was carried to the ambulance at 0936. The whole emergency process
took 44 minutes. (2.3.4,2.3.10.1)
Probable Causes
The pilot’s natural death was caused by heart rhythm disorder that was
triggered by acute cardiac artery occlusion.
Contributing Factors
1. There were no follow-up actions to further remind the pilot who
belonged to the high-risk coronary disease group.
2. According to the pilot’s physical examination records, the pilot
Recommendations
To China Airlines
made no signs of substantial improvements to his health.
1. To require the pilots to make substantial progress to the suggestions from their
medical examination doctors (ASC-ASR-00-12-011).
2. To refer to the FRAMINGHAM HEART STUDY and other systems in
evaluating whether the pilot belongs to a high-risk group of potential victims
of cardiovascular diseases and in making recommendations on how to
maintain good health. (ASC-ASR-00-12-012).
3. When hiring new pilots, the airlines should request for their recent medical
histories for the aviation medical examiner’s reference and follow-up. (ASC-
ASR-00-12-013).
4. In case of emergency, the standard phraseology should be used in the
communication between pilot, air traffic controller or relevant personnel.
(ASC-ASR-00-12-014).
5. To enhance the ground personnel’s emergency response training and
communication with the airport authorities. (ASC-ASR-00-12-015).
To Civil Aeronautics Administration, Ministry of Transportation and
Communications
1. To require the physical examination agencies to provide follow-up and
controlling regulations over the high risky pilots suffering potential cardiac
diseases. (ASC-ASR-00-12-016).
iv

2. To require the airlines or contracted aviation medical agencies to establish the
follow-up system to the suggestions of physical examiners. (ASC-ASR-00-12-
017).
3. To improve the training of Air Traffic Controller in communication and
message understanding during emergency. (ASC-ASR-00-12-018).
4. To refer to the methods and procedures for emergency responses of
international standard and international airports to review exhaustively the
emergency response plans and procedures used presently by our airports. In
addition, to establish guidelines, providing them to every airport in order to
modify their emergency response plans and procedures. (ASC-ASR-00-12-
019).
5. To improve the emergency response operational plan, procedure, and the
training of personnel in and out of the accident site in emergency medical
treatment. (ASC-ASR-00-12-020).
6. To establish the cable and radio communication equipments as well as the
operation procedure for the communication between the site commander and
the flight crew. (ASC-ASR-00-12-021).
v

CONTENTS
Executive Summary
Contents
Illustrations
Abbreviations
Chapter 1 Factual
Information
1.1 History of Flight
1.2 Injuries to Persons
1.3 Damage to Aircraft
1.4 Other damage
1.5 Personal Information
1.5.1 Basic information
1.5.2 Crewmembers' daily life in 72 hours prior to the flight
1.6 Aircraft information
1.6.1 Aircraft's basic information
1.6.2 Airworthiness and maintenance
1.6.3 Weight and balance
1.7 Meteorological information
1.8 Aids to Navigation
1.9 Communications
1.10 Aerodrome information
1.11 Flight Recorder
1.11.1 Cockpit Voice Recorder
1.11.2 Flight Data Recorder
1.11.3 Quick access Recorder
1.12 Wreckage and Impact Information
1.13 Medical and pathological Information
1.13.1 Medical care
1.13.2 Leukocytes
1.13.3 Total cholesterol
1.13.4 Physical conditions
1.13.5 Cardiogram data
1.13.6 Medical operations at CKS International Airport
1.14 Fire
1.15 Survival factors
1.15.1 Captain's incapacitation
1.15.2 Crewmembers' incapacitation procedure
1.15.3 On-board first aid
1.15.4 First aid after landing
1.15.5 Medical attendance
1.15.6 Airport emergency measures
1.16 Tests and Research
1.17 Organization and management
1.17.1 Aviation Medical Center at Civil Aeronautics Administration
(hereinafter referred to as AMC)
1.17.2 CKS International Airport Flight Operations Section
1.17.3 Asian Dispatch Center Joint Administration at CAL
1.18 Other information
vi

1.18.1
Chapter 2 Analyses
ICAO emergency classification and description
2.1 Cause Analysis
2.1.1 Examination
2.1.2 Result
2.2 Physical Examination Analysis
2.2.1 Examination equipment
2.2.2 Cardiogram data
2.2.3 Impacts of excessive leukocytes on death
2.2.4 Impacts of excessive blood fat on death
2.2.5 Comparison of physical examination system at AMC to that of
ICAO and FAA
2.2.6 AMC's examination or cardiac diseases
2.2.7 AMC's physical examination report
2.3 Airport's Emergency Procedures
2.3.1 Classification and description of CKS International Airport's
emergency procedure
2.3.2 Off-airport accident operations
2.3.3 Aviation control service
2.3.4 Fire fighting service
2.3.5 Security service
2.3.6 Airlines
2.3.7 Vehicle backup
2.3.8 Communications
2.3.9 Information telephone book
2.3.10 Airport's medical procedure
2.3.11 Gridiron pattern of the airport and its neighborhood
2.4 Airport's Emergency Operations
2.4.1 Relaying message of captain's incapacitation
2.4.2 Emergency announcement
2.4.3 Overall emergency operation
2.4.4 Relaying request for towing vehicles on ground and the response
procedure
2.4.5 Assignment of runway and message relay
2.4.6 Medical coordinator training
2.4.7 Parkng bay assignment
2.4.8 Airport's emergency aid and scene commanding
Chapter 3 Conclusions
3.1 Findings
3.2 Probable Causes and Contributing Factors
Chapter 4 Recommendations
4.1 Interim Flight Safety Bulletin during investigation
4.2 Recommendations
Number of Contents of Attachment
Attachment
Attachment 1 CVR transcript
Attachment 2 Communication transcript between CKS tower ground/fire
truck/CKS Flight Operations Section Command/ambulance
Radio (Freq.459.2MHz)
Attachment 3 Communication transcript between CI681 aircraft/CKS
vii

tower/CKS ground radio (Freq.459.2MHz)
Attachment 4 Telephone transcript between the tower and the Flight
Operations Section
Attachment 5 Telephone transcript between Taipei Regional Control
Center/CKS Approach Station/CKS Tower/Airport Flight
Operations Section
Attachment 6 Cardiogram report
Attachment 7 Aviator's physical examination standards
Attachment 8 Civil aviators physical examination manual
Attachment 9 Death cause examination report
Attachment 10 Medicament examination report
Attachment 11 First page of FAA physical examination
Attachment 12 Sec. 4.2 Off-airport accident emergency plan in ICAO Airport
Service Manual
Attachment 13 ICAO Airport Service Manual Chapter 12 Communications
Attachment 14 ICAO Airport Service Manual Chapter 9 Injury Classification
and Medical Care
Attachment 15 Aviation safety circulars during accident investigation
Attachment 16 Civil Aeronautics Administration's comments on the report
Attachment 17 CAL's comments on the report
Attachment 18 AHA/ACC Scientific
Attachment 19 Airport Operations
CONTENTS OF FIGURES
Figure 1.9-1 CKS International Airport's contacts with institutional agencies
Figure 1.11.2-1 FDR & QAR's air speed, ground speed and heading angle
Figure 1.15.3-1 Main cabin and flight attendants' allocation
Figure 1.15.6-1 CKS International Airport fire truck Assignment routing and
standby spots
Figure 1.15.6-2 CKS International Airport fire fighting effort in gridiron pattern
Figure 1.17.1-1 Aviation Medical Center's organization chart
Figure 1.17.1-2 Monthly statistics of examinees between January~December,
1999 at Aviation Medical Center Civil Aeronautics
Administration
Figure 2.2.6-1 Aviation Medical Center track cardiogram examination
procedure
Figure 2.3.11-1 ICAO airport and neighborhood gridiron pattern 1
Figure 2.3.11-2 ICAO airport and neighborhood gridiron pattern 2
viii

ACARS
Abbreviations
ARINC Communications Addressing and
Reporting System
航機通報系統
ALT Altitude 氣壓高度
CAA Civil Aeronautics Administration 交通部民用航空局
CAS Calibrated Air Speed 修正空速
CM1 Crew Member 1 第一正駕駛
CPR Cardio Pulmonary Resuscitation 心肺復甦術
CVR Cockpit Voice Recorder 座艙語音記錄器
EMT Emergency Medical Technicians 緊急醫療技術人員
FAA Federal Aviation Administration 美國聯邦航空總署
FDR Flight Data Recorder 飛航資料記錄器
FOM Flight Operation Manual 航務手冊
GSPD Ground Speed 地速
ICAO International Civil Aviation Organization 國際民航組織
MHD Magnetic Heading 磁航向
QAR Quick Access Recorder 快速存取記錄器
VHF Very High Frequency 特高頻
1

1.1 History of Flight
Chapter 1 Factual Information
When cruising at 31,000 feet after taking off at 0746 Note local time on May 8,
2000, with destination of Ho-Chi-Minh City, Vietnam, the first officer of China
Airlines' flight CI681, an A300-600R with No. B-18503, who was on control of the
flight, found out that the captain, who had just finished a passenger address when the
aircraft was turning from PARPA to KAPLI at 0815, was not right and showed no
response to the first officer's two calls. The first officer then carried out the
procedures of crewmember incapacitation and asked the chief flight attendant to reach
the cockpit. Once in the cockpit, the chief flight attendant tried to wake up the captain
and patted his face. Without having any response from the captain, another flight
attendant was asked in with an oxygen cylinder to help remove the captain from his
seat onto the forward galley floor. At the same time, a passenger address was made by
the cabin crew to ask for a doctor on board to provide assistance. The first officer then
made the decision of turning back to Taipei CKS Airport. With the help of the
volunteered doctor on board, the flight attendants kept on performing CPR to the
captain.
At 0816, the first officer advised Taipei Regional Control Center of the
captain's incapacitation, though he failed to use "emergency" terms. At 0821, the first
officer then advised Asian Dispatch Center of Joint Control, China Airlines and asked
towing vehicle and ambulance to stand by.
At 0831, during the turning back, the first officer made a request to the air
traffic controllers for first priority. During the approach, the air traffic controllers
assigned the aircraft to use Runway 06 for the aircraft had been assigned to park at the
south-parking bay. After making anther request by the first officer, the Runway 05
Left was assigned to the CI681. At 0850, the first officer landed the aircraft on
Runway 05 Left on autopilot and then stopped at N7 taxiway and was waiting for
towing vehicles to bay 608. Before landing of the aircraft, airport ambulances, doctors
and nurses from the contracted hospital were already standing by at parking bay 608.
The towing vehicle arrived at 0901. At 0904 it began towing the aircraft
eastward by passing through the taxiway to arrive the parking bay 608 at 0920. The
contracted physicians and first-aid personnel embarked the aircraft to carry out the
rescue effort. At 0938 the captain was carried on board of the ambulance and at 0947
reached MinShen Hospital, Tao Yuan. At 1020, the captain was announced dead in
that hospital.
2

The incident, from the first officer's first notice at 0816 to the Taipei Regional
Control Center regarding the captain's incapacitation to the aircraft's landing on
Runway 05L and stopping later on the taxiway at 0852, lasted 36 minutes.
minutes.
The towing began at 0852 and reached the parking bay 608 at 0920, lasted 28
The captain was moved onboard of the ambulance at 0936, 44 minutes after
the aircraft stopped on the taxiway (at 0852).
1.2 Injuries to Persons
Casualty Pilot Flight
attendant
Passenger Others Total
Death 1 0 0 0 1
Serious
injury
0 0 0 0 0
Minor injury 0 0 0 0 0
No injury 1 12 265 0 278
Total 2 12 265 0 279
1.3 Damage to Aircraft
The aircraft suffered no damage.
1.4 Other damage
There are no other damages.
1.5 Personnel information
1.5.1 Basic information
Description Captain First officer
Sex Male Male
Age (years old) 45 27
Date of admission to CAL Feb. 15, 1998 Aug. 18, 1998
Foreign temporary license Commercial aircraft pilot
License/expiration
/Jan. 31, 2001
Captain certificate for
A300-600R
issued by CAA
Co-pilot certificate for
A300-600R
/March 13, 2001 /June 18, 2001
FAA certificate
FAA certificate
/Apr. 30, 2003
/July 31, 2004
Class A pilot physical Class A pilot physical
examination certificate examination certificate
/May 31, 2000
/Aug. 31, 2000
3

Total flying hours 10559 821
Flying hours in last 90
172
days
154
Flying hours in last 60
143
days
108
Flying hours in last 30
95
days
70
Total flying hours for said
1375
model of aircraft
412
Time after last flight 16 hours 44 hours
1.5.2 Crewmembers' daily life in 72 hours prior to the flight
1.5.2.1 Captain
The captain was not on duty on May 5. On May 6, he had a flight from Taipei to
Hong Kong and continued from Hong Kong to Kuala Lumpur. On May 7, he flew
from Kuala Lumpur to Hong Kong and then from Hong Kong to Taipei.
1.5.2.2 First officer
On May 5, the first officer had a flight from Taipei to Kaohsiung and continued
to Hong Kong. On May 6, he flew from Kaohsiung to Taipei and was off on May 7.
1.6 Aircraft information
1.6.1 Aircraft's basic information
Aircraft information
1 Aircraft No. B-18503 2 Date of manufacture Sep. 9, 1998
3 Registration No. 87-713 4 Service hours 4560:14
5
7
9
Airworthiness
Certificate No.
Date of last shop
check
Date of last weekly
check
88-09-116 6
Dec 27, 1999 8
May 02, 2000 10
1.6.2 Airworthiness & maintenance
Expiration of
Airworthiness
Certificate
Service hours since
last shop check
Type of last weekly
check
Sep. 10, 1999 -
Aug 31, 2000
1047:52
C Check
Both the maintenance and airworthiness of this aircraft meet the requirements of
the Civil Aviation Law.
4

1.6.3 Weight and balance
The Weight and Balance Manifest - load sheet of the aircraft indicated that
scheduled landing weight of the aircraft upon arrival at its original destination was
298,684 lbs and the specific gravity was at 25.9 % MAC c.g.
Due to the almost immediate return after its takeoff, the mean landing weight of
the aircraft at CKS International airport was 330,353 lbs, exceeding 308,648 lbs., the
rated maximum landing weight. Once on ground, the mechanics proceeded with the
"Overweight Landing" inspection as suggested by the maintenance manual and found
no irregularities. The aircraft was signed and returned to service.
1.7 Meteorological information
Prevailed by a split high pressure over Taiwan, the day was fine yet cloudy. The
meteorological information recorded in CKS International Airport at 0800 was as
follows: Wind direction 080 o , wind speed 14 knots, visibility over 10 km, few clouds
at 1,200 feet, few clouds13,000 feet, scatter 20,000 feet, temperature 25°C, dew point
19°C and altimeter setting 1011pa.
1.8 Aids to Navigation
The day of the incident, the navigation aid and guidance facilities on Runway 05
Left at the CKS International Airport were normal.
1.9 Communications
On the day of the incident, the condition of the communication between the
aircraft to Taipei Regional Control Center, CKS Approach, and the tower were normal.
The condition of the communications between the aircraft and the airline's ground unit,
the Asian Dispatch Center, was normal as well.
The cockpit voice recorder (CVR) transcript was shown as Attachment 1. The
communication transcript between CKS ground control in tower/fire station/CKS
Flight Operations Section Command/ambulance Radio (Freq.459.2MHz) was shown
at Attachment 2. Communication transcript between CI681 aircraft/CKS tower/CKS
ground radio (Freq.125.1/118.7/121.9MHz) was shown as Attachment 3. The
Telephone transcript between the tower and the Flight Operations Section was shown
as Attachment 4 and Telephone transcript among Taipei Regional Control
Center/CKS Approach Station/CKS Tower/Airport Flight Operations Section was
shown at Attachment 5. The ATC transcript showed the first officer asked Taipei
Regional Control Center to contact CKS Airport for ground support. For contacts
between CKS airport and relevant agencies, there were either exclusive frequencies,
5

or direct telephones. The communications between CKS Airport and the related
agencies was shown in Fig. 1.9-1.
Fig. 1.9-1 Contacts between CKS Airport and all agencies
Flight Service Station Telephone CAA
Telephone Telephone
Control Tower Frequency 459.2 Airport Aviation Div.
(Agent/Vehicle)
Air-craft
Freq.131
.3
Airline
Flight
Service
Ground
Service
Compan
y
Aviation
Police
Commanding
Center
Central
Control
Center
Air-port
Fire
squad
Freq.459.2 Freq.459.2
Emergency Medical
Service
Fig. 1.9-1 Contacts between CKS Airport and all agencies
1.10 Aerodrome Information
The elevation of the CKS Airport was 107 feet and the end of Runway 05 Left
was 73 feet. Runway 05 Left was 12,008 feet in length (3660 meters). The cement
runway was heading at 053° and was dry with no rain.
Runway 05 Left was the only runway available for auto landing at CKS Airport.
All accidents in airport would notify the Flight Operations Section first. In case
of any injury at the airport, the Flight Operations Section should then advise the fire
fighting squad or the MinShen Hospital, the contracted medical treatment agency with
the airport authority
1.11 Flight Recorder (FDR)
1.11.1 Cockpit Voice Recorder (CVR)
The solid-state Cockpit Voice Recorder was a FAIRCHILD A200S model, with
Part No. S200-0012-00 and Serial No. 01566. The voice data lasted 120 minutes and
6

covered from aircraft engine start, taxi until its safe landing and connection to the
towing vehicle. The transcript in association with this incident was provided as
Attachment 1. The transcript covered: Regional Control Center's instructions to guide
the aircraft to fly toward Hsikang (08:00:18) until the aircraft's landing and towing by
the towing vehicle to Parking bay 608. (Recorder stops at 09:05:40)
1.11.2 Flight Data Recorder
The solid-type Flight Data Recorder was a FAIRCHILD F1000, with Part No.
S800-2000-00 and Serial No. 02008. The total flight data covered 61 hours, 5 minutes
and 48 seconds. Of all the decoded key parameters, 9 (ALT, CAS, GSPD, HEADING,
LAT POSITION, LONG. POSITION, NOSE WHELL POSITION, PITCH and
ROLL) were compared with the data in QAR. The results turned out to be identical, as
shown in Fig. 1.11.2-1.
1.11.3
Fig.
1.11.2-1 FDR and QAR air speed, ground speed and heading angle
Quick Access Recorder (QAR)
The magnetic tape QAR had 258 flight parameters. With the assistance
of CAL's
Flight Safety Division, the QAR were decoded.
After decoding QAR, we had the following information:
7

Aircr aft's takeoff time: 07:46:17 (CAS=171 KTS; MHD= 52 DEG;
CG%=26.2%) from CKS' Runway 5.
Aircraft's landing time: 08:50:14 (CAS=145 KTS; MHD= 55 DEG;
CG %=26.2%,Vertical g:1.12) at CKS' Runway 5L.
Aircraft's stop time: 08:52:06 (CAS=30 KTS; GSPD= 0 KTS).
Aircraft’s return position and time: After passing over Hsikang, Tainan, the
aircraft reached its maximum distance from CKS Airport,
74kms southwest Kaohsiung and its altitude of 31,000 feet.
1.12 Wreckage and Impact
Information
1.13 Medical and
Pathological Information
Excessive
leukocytes had been detected in each of physical examinations. Only
when the number of leukocytes in re-checks dropped to 10,000 or below, the captain
passed the examinations.
1.13.3
aircraft flew southward along A577. Its return began at 37.5Kms southwest
of Kaohsiung and crossed G581 Air Way. Finally, the aircraft took the
original departing route to return back to CKS International Airport. At
08:17:40, the
Not applicable.
1.13.1 Medical care
Except the physical examination data, the captain's medical record filed in the
Aviation Medical Center, CAA showed no records of medical treatment and services.
The physical examination data included the re-check records of excessive leukocytes,
cardiogram and X-ray.
1.13.2 Leukocytes
The total cholesterol
In each of the physical examination s, the captain's total cholesterol exceeded
the
standard l evel of 122-200 m g/dl.
The aviation medial doctor did not ask the captain to
recheck due
to his low data of high-density cholesterol. The physical examination
doctor suggested the capta in to do more exercise and to be careful to have a diet.
The following
data showed the total cholesterol and leukocytes of the captain as
recorded between
Nov. 27, 1997 and Nov. 25, 1999 and the doctor's
suggestions:
8

E xamination
Leukocyte
date
Nov. 27,
1997
Recheck
Dec.04, 1997
Total
cholesterol
Highdensity
cholesterol
14,400 233 34 6.8
9,200
May 8, 1999 13,500 240 33 7.3
Recheck
M 8 10,000
ay 21, 199
Finding
Ratio Leuko Blood
cyte
fat
Too
high
──
Recheck
Leukocyte
Too
high
Doctor's suggestions
── Recheck
Leukocyte
yte
Nov. 6, 1998 14,500 233 30 7.7
Too
high
counts. Liver function
1-month
certificate
──
Irregular leukoc
ALT. Recheck late
Dec.
Leukocytes remain
Recheck
high in recheck.
Dec. 22, 12,400
Recheck in blood
1998
outpatients for
Recheck
Feb. 12, 1999
tracking. Quit smoking
14,400
No immediate cause to
excessive leukocyte.
Recheck in blood
outpatient service for
determination.
Recheck
Apr. 14, 1999
9,800
May 18, 1999 10,000 218 33 6.6 ──
Low
cholest- Appropriate exercises,
ero l of
high
quit smoking
density
Nov. 8, 1999 12,400 239 43 5.5 Excess
ive
──
Self-declared
periodontitis, excessive
cholesterol, irregular
liver function
and
requests for checks by
dentist. Blood and liver
shall also be checked.
Eat only low-fat, lowsugar
and no fried
food.
Periodontitis checks
Recheck
showed normal blood,
normal liver function,
Nov. 25, 10,000
no hepatitis type B or
1999
AIDS. Certificate
Joint
issued.
tracking.
Requires
diagnosis
No acute periodontal
with dentist
inflammation.
Nov.
1999
25,
Requires tracking.
9

1.13.4 Physical conditions
The incapacitated captain who was a husky male of 40-50 years old; had
excessive high total cholesterol; was a smoker and categorized to be in the high risk
potential cardiac diseases group (Attachment 18). In his flight suitcase, the captain
carried a number of medicaments, though there was nothing in association
with
cardiac
heal or health care.
1.13.5 Cardiogram data
Communications,
CKS Airport is to have 2 doctors and 3 nurses. CKS Flight
Institutional Air Stations of Civil Aeronautics Administration under the Ministry of
Transportation
and Communications, ”Subject to the commanding and supervision of
Aviation Chief, the doctors treating patients shall have
the following duties: 1. First
aid or
transfer of injured personnel or patients requiring emergency services. 2.
Planning,
ordering, safeguarding and use of medical materials and medicaments.”
Having a contract with
CKS Airport, Mingsheng Hospital, Tao Yuan maintained
one doctor and one nurse at the airport's clinic to carry out preliminary checks,
bandaging and first treatment in case of accident and serious incident.
There were one airport nurse; one doctor
and one nurse of Mingsheng Hospital
to organize the emergency medical team on that day.
day.
The 3 dynamite cardiogram data of the captain showed no abnormal record of
the heart. The results of the 3 checks are given in Attachment 6.
1.13.6 Medical operations at CKS International Airport
CKS International Airport had its own medical team and facilities, though there
is no first-aid procedure available.
In pursuance of Organic Regulations of Institutional Air Stations of Civil
Aeronautics Administration under the Ministry of Transportation
Operations Section has 3 nurses at this time. In Art. 13 of the Operational By-law of
See 1.15, Survival Factors for the emergency
medical treatment preceded that
1.14 Fire
Not applicable.
10
and

1.15 Survival Aspects
1.15.1 Captain's Incapacitation
The aircraft controlled by the first officer (Pilot Flying, PF)
took off at 0746
from CKS International Airport to undergo a normal flight. During cruising flight, the
first officer gave his welcome announcement via passenger address in Chinese. At
0808 the captain made his English-language announcement and at 0813 chatted with
the first officer. At 0815, when the aircraft was approaching PARPA INTX and ready
to make a right turn to KAPLI, the first officer found that the captain was not
concentrating at the maneuvering of the aircraft and was breathing deeply; his right
cheek slightly shaking; his body tilting leftward and the face slightly up; his eyes
under the sunglasses slightly open and not responsive at all to the questions of the first
officer.
1.15.2
Crewmembers' Incapacitation Procedure
The first officer immediately
executed the crewmember incapacitation
procedures of Flight Operation Manual
(FOM) and called the chief flight attendant to
the cockpit
for assisting. The chief flight attendant checked the captain's condition by
padding his cheeks twice and found the captain still no response. The chief flight
attendant then requested the flight attendant in main-cabin take the oxygen cylinder
for first
aid. After 5 to 10 seconds, the captain was not breathing. During that time the
chief flight attendant let the flight attendant make a passenger announcement if there
were any doctor on board and asked the Z1 flight attendant be seated in the captain's
seat and share some of the first officer's work. At the same time, the first officer made
sure of the captain's incapacitation and decided to turn back to CKS International
Airport.
1.15.3
On-board first aid
A volunteered doctor on board was led into the cockpit by a flight attendant to
check the captain's condition. The preliminary check determined that the captain
showed no heartbeat, breath and developed in continentia urine and mydriasis.
At about 0820, instructed by the doctor, the chief flight attendant and a flight
attendant moved the captain to the forward galley (G1)(See Fig. 1.15.3-1 Main cabin
and flight attendants' allocation) to conduct CPR. During the rescue, the doctor was
trying to open the captain's throat and trachea to let the air into the lungs, to remove
the vomit and asked for cardiac pads, laryngoscope, oxygen tubes and phlegm
11

extractor, cardiac pads to resuscitate the heart beat again. The flight attendant
said that
there was no laryngoscope, oxygen tubes or phlegm extractor.
While the chief flight attendant kept on doing the chest massage of CPR, the
doctor on board gave instructions on artificial respiration and, with the help of a flight
attendant (4L) who was a registered nurse and kept on checking the captain's
pulse,
breathing and pupils. After 20 minutes of CPR, the captain did throw dark-gray vomit.
Figure 1.15.3-1 Main cabin and flight attendants' allocation
The on-board emergency effort continued the CPR from 0825 to 0925, and then
the task was taken over by the MinShen Hospital medical team, CKS Airport.
The doctor on board let MinShen Hospital medical team take over the first-aid
effort and said that the captain was in shock condition after the aircraft came to a stop.
1.15.4 First aid after landing
At 0850, the aircraft landed at CKS Airport's Runway 05 Left and was towed to
parking bay 608 at 0920. When MinShen Hospital medical team went on board the
aircraft,
the captain showed no response at all and his mydriasis had no neck pulse.
Laryngoscope was used and oxygen tube inserted while serum was applied at the
same time as the CPR effort was carried on. The doctor of MinShen Hospital said that
because of the confined space on board and no response of the patient during the
12

escue effort, he had to decide to let the captain be rushed to Da-Yuan Min-Shen
Hospital for rescue.
1.15.5 Medical attendance
At 0936 the captain was moved onto the ambulance, where the MinShen
Hospital's doctor and the CKS nurse kept on with their first-aid effort. At around 0947,
the ambulance arrived at Da-Yuan
MinShen Hospital. At 1020 the unsuccessful first-
aid effort stopped and the captain was declared dead. The diagnosis certificate of
MinShen Hospital stated that the captain had passed away before his arrival at the
hospital.
1.15.6 Airport Emergency Responses
The following is a summarized timetable of the emergency first aid. More than 1
occurrence may appear in one line. The recording time in different agencies was
unable to be synchronized.
Airport Emergency Responses Timetable
Sources:
FDR,
CVR,
CI681 operation flow chart of Tao Yuan Airport Service Control Center,
Irregularities Report of CAL Asian
Dispatch Center Flight, CI681 Return Incident
Report of CKS
Flight Operations Section, Assignment Record of Fire Squad of CKS
International Airport, CI681 Operation Processes of TASCO(Tao Yuan Airport
Service Company) Parking Bay Section, Transcripts of Aircraft/CKS Approach
/CKS Control Tower/CKS Ground Control (Frequency 125.1/118.7/121.9MHz),
Transcripts of CKS Control
Tower Ground Control/Fire truck/CKS Flight Operations
Section Commander/Ambulance (Frequency 459.2MHz), Telephone transcript of
Control Tower
& Flight
Operations Section, Transcripts of Taipei Regional Control
Center/CKS Approach /CKS Control Tower/ CKS Flight Operations Section internal
telephone.
Time Status
FDR074617 CI681 took off normally from CKS Runway 05 Left carrying
2 pilots, 265 passengers and 12 flight attendants.
CVR081519 First officer found out abnormal condition of captain (FO: Are
you all right?)
CVR081630 First officer decided to turn back (FO to Area control…back to
Taipei…. also
requesting ambulance stand by in Taipei.
CVR081644 FO to Area control: the captain incapacity, we need ambulance
standby in Taipei…
CVR081721 FO to Area control: one ambulance stand by, please
Air control record Taipei Area control advised control tower that CI681 carrying
time
081748 1 sick passenger and requesting for standby ambulance.
Flight Operations Control tower advises Flight Operations Section on-duty 681
Section
record time returns with 1 ill passenger
and asks for designated parking
081823 bay.
13

CVR081943
The on-duty officer of Flight Operations Section relayed
message to Asian Dispatch Center of CAL to provide an
ambulance.
Area control center instructed to prepare a TIA Instrument
Landing
CVR082136 First officer said to CAL OD:‘CI681 returning to Taipei,
captain passed out, I am coming in and will land at Taipei.
Request towing vehicle to stand by at the runway. I do not
intend to taxi the aircraft. I am busy and have no time to
prepare (to taxi) .’
CAL Asian D ispatch Asian Dispatch Center of CAL report indicated: CI681 first
Center record tim e officer reported to Asian Dispatch Center that the first officer
0805
requested for return because captain had passed out.
CVR082200 First officer to Asian Dispatch Center of CAL:‘Not sick
passenger. It is the captain who had passed out. I am turning
back, I have no time to talk to you. Please have an ambulance
CAL Asian Dispatch and a towing vehicle to standby. This is it. Thanks.
Center record time D1 of Asian Dispatch Center of CAL advised his supervisor,
0810
Joint Control of CAL, Flight Operations Section
of CAA..
The said Supervisor of CAL advised the Director of Aviation
Joint Control and Division of Flight Safety of CAL.
CVR082324 First officer requested to land on Runway 05 Left
ATC082339 The on-duty officer of Flight Operations Section checked with
Tao-Yuan Aviation Service Company for available parking
TAS record time
0825
bay and reminded control tower to assign 608 BAY to CI681.
CVR082404 First officer requested again
for landing on Runway 05 Left.
Flight control recordAirport
Flight Operations Section advised Control Tower to
time 082510 confirm that the captain had passed out, and the control tower
relayed the message to Taipei Approach.
CAL Asian Dispatch CAL Asian Dispatch Center informed Flight Operations
Center record time Division
of CAL regarding the captain's passing out.
0820
Flight Operations Flight Operations Section confirmed the captain's passing
out
Section record time from Asian Dispatch Center and informed the On-duty Officer
0825
of Flight Standard Division, CKS office, Airport Central
Control Center; asked for fire trucks and ambulances
to
standby at Runway 06.
Fire squad record Airport Central Control Center advised the fire squad to have
time 0825
ambulance standby at parking bay 608.
Fire squad record Airport fire squad ambulance carrying 1 nurse , 1 EMT1
time 0827 personnel and 2 certified nurses arrived the 608 bay.
Fire squad record Control tower advised the fire squad chief that aircraft with
time 0828 captain passing out was
approaching to Runway 06.
Fire squad record Fire trucks from South and North stations arrived at S8, S5
time 0830
standby area respectively. Fire truck 1 advised ambulance at
parking bay 608 to changed to S5 standby point.
CVR083117 Pilot called Taipei Area Center for priority to approach.
14

CVR083234 The flight attendant who sat at captain's seat advised Asian
Dispatch Center of CAL that the captain had been moved to
the forward galley.
TASCO record time CAL informed Tao Yuan Airport
Service Company
0 835
( TASCO) to prepare a wheelchair for sick people. TASCO
suggested to use a stretcher for passed-out
passenger.
(Stretcher with a lift).
Mingsheng Hospital CAL advised Mingsheng Hospital
at 0830 and 0840 regarding
record time 0830- a passed-out passenger without describing the detail. At 0840
0840
medical personnel carrying first-aid gears, serum and oxygen
for general condition rushed to 608 BAY via CAL vehicle.
CVR083646 ATC
advised first officer that using 06 for landing. ‘CI681
affirmative and depart B DME fix, turn right intercept
ILS
runway 06 final approach course by yourself’
CVR083656 ‘CI681 confirm and request 05L’
CVR083716 ATC made corrections for landing on 05L
‘CI681 depart Xerox correction, depart DME fix intercept
runway 5L localizer over’
CVR083852 Asian Dispatch Center supervisor relayed the telephone
CAL Asian Dispatch message of Director of Flight
Operations of CAL to first
Center record time officer
to carry out an Auto-land.
0835
TASCO record time A Stretcher with elevator was standing by at Bay 608.
0840
Fire squad record Control tower advised the fire squad at 0842 that the aircraft
time 0842 would
land on Runway 05L.
Fire squad record Fire
trucks and ambulances moved to N6 and N10 stand by
time 0845
positions.
CAL Asian Dispatch The
chief pilot of CAL A300-600 asked the on-duty
Center record time supervisor to relay the message to CI677 crew to provide
0846 assistance to CI681 crew.
FDR085014
CVR085037
The aircraft landed.
Fire squad record
time 0850
CAL Asian Dispatch
Center record time
0852
TASCO record time
0850
FDR085206 Aircraft stopped on N7 next to 23L.
CVR085208 The
first officer reported to have stopped the aircraft on N7.
CVR085211 Ground
controller called whether he needed a towing vehicle.
CVR085221 Ground controller called whether he needed a towing
vehicle
again and said the aircraft was assigned to Bay 608.
CVR085226 Ground controller called the aircraft to stop at N7.
15

CVR085311 The first officer checked with Asian Dispatch Center how long
the
towing vehicle would arrive.
CAL Asian Dispatch
Center record tim e Dispatcher D1 called CAL TPEMM to send a towing vehicle
0855
for CI681.
CAL Asian Dispatch
Center
0900
record time Dispatcher called TPEMM again for
towing vehicle.
CVR085329 Ground controller called the aircraft to taxi to N7 next to N9.
FO did not taxi.
Fire squad record Control tower advised the fire squad to return to station but the
time
0853
commanding vehicle 108 and ambulance kept on watching
the aircraft.
CVR085403 Ground controller called the aircraft to stop moving. (Fire
truck moved back to station.)
Air Traffic control Through control tower, Flight Operations Section checked
record time 085440- whether the towing vehicles arrived, if not, would ask the
085500
aircraft to shut down the engines.
CVR085507 Ground controller asks aircraft to shut down the engines.
CVR085543 The FO called Asian Dispatch Center
for towing vehicle.
TASCO record time Asian Dispatcher of CAL advised TASCO for towing service
0856
to 608 BAY via N7.
CAL Asian Dispatch Asian Dispatcher of CAL called TASCO for towing service.
Center record tim e
0902
TASCO record time Joint Control of TASCO advised the Ramp Service Section
0857 to let the towing car at the North BAY A6 to tow the aircraft.
CVR085758 Dispatcher of CAL called the FO to check with control tower
to taxi the aircraft to parking bay.
Air Traffic Control Inspector of Flight Standard
Division called the control tower
record
time 085827- not to allow the aircraft to taxi. The towing car arrived before
090050
the the information was issued by the tower.
CVR085833 FO called control tower for restarting engines
CVR085839 Control
tower approved the restarting and the taxi to parking
bay.
CVR090040 FO called that towing vehicle arrived and shut down engines.
CAL Asian Dispatch
Center record time
0905
16

CVR090439
TAS
0904
record time
Towing aircraft started.
CAL Asian Dispatch
Center record time
0906
CAL Asian Dispatch Dispatcher D1 confirmed to Ground Service Department
Center record time (TPETTCI)that
ambulance wais at BAY 608.
0910
TAS record time Towing vehicle towed the aircraft to BAY 608. Lift cart R1
0920
FO reports 0921
and ladder L1 connected to the aircraft.
Fire squad record The Captain had undergone onboard first aid by MinShen
time 0936
Hospital's medical team and CKS nurses and then moved to
the ambulance through lift cart.
The doctor on board and chief flight attendant performed CPR
to the captain since his illness started until the arrival of
MinShen Hospital's medical team and CKS nurses.
Fire squad record While captain was rushed to MinShen Hospital Da-Yuan, a
time 0938
notice of the pilot’s sick condition was given to the hospital
for preparing the necessary equipment.
Fire squad record The sick Captain was sent to the hospital.
time 0947
1.15.6.1 Airlines
Asia Dispatcher Center of Joint Control Division, CAL is responsible for
contacts between the crewmembers and other supporting ground units.
Interview data indicated that upon receiving the FO's information regarding the
captain's
unconsciousness and the request of turning back with the need of ambulance
standing by, the dispatcher failed to catch up the FO's request for a towing vehicle at
runway end as well as never realized that FO was not allowed to taxi. (It was
stipulated in Section 2, Chapter 4 of the Flight Operation Manual. “Only a captain
[CM1] is authorized
to taxi a passenger aircraft”.
Asia Dispatcher Center issued the notice of captain passed-out to Joint Control
Division, Flight Operations Division, Flight Safety Division of CAL and CKS Flight
Operations Section after its communication to CI681's FO. Asia Dispatcher Center
knew the aircraft was assigned to Bay 608.
At 8:30, MinShen Hospital was contacted and requested for medical backup. At
0845, the medical team was rushed by CAL van to parking bay 608. At the same time,
through CAL, the CKS Central
Control Center received the message of CI681's return
and the request for ambulance.
17

At 0830 CKS Flight Operations Section advised TASCO that CI681 was coming
back and would stop at parking bay 608. At 0835,
CAL asked TASCO to provide a
wheelchair. TASCO suggested to provide a stretcher and ambulance that would fit the
unconscious
patient. At 0840, both the ambulance and the stretcher were ready at
parking bay 608.
At 0852 the CI681 landed. FO checked the status of towing vehicle with Asia
Dispatcher Center. Asia Dispatcher Center then made a second request to CAL
Engineering and Maintenance Division for a towing service but failed. At 0856 Asia
Dispatcher Center asked TASCO to provide towing service. The towing vehicle
started
towing at 0904 and finished towing the aircraft on parking bay 608 at 0920.
The ladder connected on lL door and the ambulance (carrying MinShen medical team)
approached to 1R door.
1.15.6.2 CKS International Airport
At 0818, the
Information Branch of CKS Flight Operations Section received the
notice
from the control tower that CI681 had an ill passenger and requested for air
turning back with ambulance service on ground. Flight Operations Section of CAA
then relayed the message to Asia Dispatcher Center of CAL to call for ambulance, to
understand the status of the sick passenger. At the same time, a reply
was sent back to
the control
tower to assign the aircraft to stop at parking bay 608 after landing.
At 0825 CKS Central Control Center advised to have ambulances standby at
parking bay 608. An ambulance carrying 1 nurse and 3 EMT1 fire fighters rushed to
the parking bay.
At 0825 Asia Dispatcher Center of CAL replied to Flight Operations Section of
CAA by stating that it was the captain had passed out. Flight Operations Section then
relayed the information to CAA,
Director of CKS Airport and the CKS Centralized
Control
Center.
The ambulance arrived the Bay 608 at 0827. At 0828, the control tower advised
the fire squad that the aircraft carrying the unconscious captain was coming back and
would land on Runway 06. Fire trucks were dispatched. The ambulance was
instructed to meet the fire trucks at the southern standby position.
At 0835, the fire trucks were on S5 taxiway (fire trucks 1, 3, 5 and 16,
ambulances and 108 fire-fighting commanding vehicle) and S8 taxiway (fire trucks 4,
6, 7 and 8). Flight Operations Section's No. 103 vehicle was then standby on S1
taxiway. See Fig. 1.15.6-1 and
Fighting
gridiron.
Fig. 1.15.6-2 for CKS International Airport Fire
18

At 0838 the control tower advised Flight Operations Section that the aircraft was
to land on Runway 05 Left.
At 0845, the fire trucks and ambulances moved to N6 taxiway (fire trucks 1, 3, 5
and 16, ambulances and 108 fire-fighting commanding vehicle) and N10 taxiway (fire
trucks 4, 6, 7 and 8)to standby. Flight Operations Section's No. 101 vehicle parked on
05R and No. 103 vehicle standby on N6 taxiway while No. 105 vehicle stopped on
domestic parking bays as planned.
At around 0850, the aircraft landed on Runway 05 Left and vacated the runway
on N7
before reaching the Runway 05R. At 0852, the fire trucks at the North and
South stations left except the #101 、 #108 commanding vehicles and ambulance
stayed at the back of the aircraft.
Section Chief. At 0852 the scene commander asked the control
tower why the aircraft
stopped.
The control tower replied by saying that the aircraft was requesting for a
the scene
commander that Asian Dispatch Center of CAL relayed the message that the
first officer showed intention of proceeding to parking bay 608 on his own and was
requesting guidance from the scene commander's vehicle. The towing vehicle arrived
at 0901 and started towing the aircraft at 0904. The aircraft was towed along Runway
05R and into the East Cross Taxiway before turning right to SP Taxiway.
At 0920 the aircraft was towed to parking bay 608, where the medical team was
standby with first-aid equipment. The ladder and the patient lifter were put onto the
1L and 1R door of the aircraft. The 1R door was opened from inside with some delay
and was not opened by the ground personnel. According to interview data, the same
one flight attendant opened both the lR and the 1L door.
Once the doors opened, CAL personnel, CKS Airport Flight Operations Section
personnel and CKS nurses entered into the aircraft from the 1L door and MinShen
Hospital's medical team and nurses entered from the 1R door to perform the first-aid
task.
The scene commander was the CKS International Airport Flight Operations
towing. At 0855 the commander asked TASCO about location of the towing vehicle
and TASCO replied that the vehicle was preparing. At 0858 the control tower advised
19

Fig.1.15.6-1 The fire truck Assigned Routs and Standby Positions at CKS
International Airport
20

Fig. 1.15.6-2 The fire-fighting gridiron of CKS International Airport
21

1.16 Tests and Research
Not applicable.
1.17 Organization and Management
1.17.1 Aviation Medical Center at Civil Aeronautics
Administration (hereinafter referred to as AMC)
1.17.1.1 Aviation Medical Center's organization chart
Beside the Aviation Medical Management Committee that supervises the
Aviation
Medical Center, there is a Medical Affairs Deliberation Committee that is
responsible for the review of suspicious matters. The organic chart is given in Fig.
1.17.1-1.
Aviation Medical Management
Committee, Civil Aeronautics
Administration
Aviation Medical
Medical Affairs Review
Board, Civil Aeronautics
Advisor Director Administration
Medical Assistant Deputy Director
Administra
tion
Medical R & D Nursing Medical Physical
administration services examinations examinations
Fig. 1.17.1-1 Aviation Medical Center's
organic chart
1.17.1.2 Aviation Medical Management Committee,
Civil
Aeronautics
Administration
The Aviation
Medical Center was founded in November 1970.
The Aviation
Medical Center was the only agency responsible for physical
examinations of all national aviators and foreign aviators working in local airlines.
The Aviation Medical Management Committee, Civil Aeronautics
Administration,
directly supervised
the Aviation Medical Center.
The Aviation Medical Management Committee, Civil Aeronautics
Administration was organized by the Director General of CAA, two Deputy Director
22

General, Director
of Planning Division, Director of Air Traffic Control Division,
Director of Personnel Affairs Division, Chief Account of CAA, Director of Internal
Affairs Division
and a number of aviation medical advisors who would offer their
specific opinions
when necessary.
1.17.1.3 Medical team
The Director of Aviation Medical Center
recruited all the medical team and the
administration personnel when approved by CAA. The remuneration was determined
by each
of the personnel’s seniority. They did not require the qualification of public
servants.
Currently there were 6 doctors in Aviation Medical Center. Four of them
worked as full time and 2 were part-time. Of the 8 nursing personnel,
dietician, 3 were testers and 2 were psychologists.
1 was a
Institutionally, the Director and the Deputy Director of Aviation Medical Center
performed both medical and administrative duties. The remuneration of the recruits
was sourced from the collected physical examination fees of the aviators. C AA did
not have budget for the salary of the recruits.
1.17.1.4 Responsibil ity
of Aviation Medical Ce nter According to the information provided by Aviation Medical Center, its
obligation a nd duties were described bel ow:
Obligations: 1. Aviators' physical examinations.
Duties:
2. Avia tion physiological education a nd first a id traini ng.
3. Medical investigat ions and suggestions o n aviation accidents. 1. Aviators' physical examination and preventive health
operations.
2. Psychological consultation and guidance.
3. Statistical analysis of medical information.
4. Crewmember evacuation education and first-aid training.
care
5. Supervision and suggestions on airport first-aid facilities and
catering sanity affairs.
6. Suggestions on revisions of aviation physical examination standards.
7. Civil aviation medical research.
23

8. International aviation medical exchanges.
1.17.1.5 Physical examinations
Physical examinations at Aviation Medical Center were conducted on weekday
mornings. The entire medical and the examination team were fully dedicated to this
task. In average, there were 30-40 people to take Class A, B and C examination. Each
of on duty doctors was responsible for the final examination of 5-8 aviators.
Table 1.17.1-1 Physical Examination Statistics of Aviation Medical Center
Jan.~Dec. 1999
Jan. Feb. March April
May June July Aug. Sep. Oct. Nov. Dec. Total
Pilot 360 370 413 306 370 340 386 361 398 309 390 330 4333
Flight engineer 5 1 1 9 16 6 8 5 10 9 1 1 72
Airborne 1 0 0 0 0 5 0 0 0 0 0 0 6
photographer
Flight attendant 115 136 179 148 96 143 120 246 193 258 132 131 1897
Controller 23 4 8 10 15 21 10 69 64 47 18 16 305
Ground 114 159 120 153 146 151 156 140 119 124 181 183 1746
mechanics
Assignor 32 17 22 27 23 20 21 18 22 18 22 27 269
Administrative 0 0 31 3 0 1 4 34 10 19 13 2 117
executive
Commissioned 2 1 0 3 0 2 3 4 1
physical
examination
1 3 0 20
Fire fighter 0 0 0 0 0 0 0 0 0 0 0 0 0
Others 1 1 0 0 1 1 7 2 0 0 0 0 13
(swimmers)
Total 653 689 774 659 667 690 715 879 817 785 760 690 8778
1.17.1.6
Legal grounds for physical examination and standards
The Aviation Medical Center performed the physical examination tasks in
accordance with the Civil Aviation Code 05-03A, i.e. the “Aviator’s Physical
Examination Standards" (See Attachment 7), originally issued on Nov. 17, 1973 and
reissued the 7th revisions of Chi-fa-fa No. 0002 Order on Feb. 2, 2000 from Civil
Aeronautics
Administration, Ministry of Transportation and Communications. The
physical examination
tasks were conducted by following the "Civil Aviators' Physical
Examination Manual" (See Attachment
8), which had been prepared by Aviation
Medical
Center in 1994 and then revised in 1996. This manual provided the guidance
only while the physical examination doctors should conduct all physical examination
in accordance with "Aviator's Physical Examination Standards". Different items
would be conducted accordingly to the type of license of the examinee.
For further examination of suspected
abnormal cases, Aviation Medical Center
should follow the "Aviator's Physical Examination
Standards" to assign a specific
24

medical
institution or a specialized doctor to conduct the examination. The physical
examination doctor of Aviation Medical Center should compile the results and
comments to submit to the Review Board of Aviation Medial Center of CAA for
discussion and decision. The Director of the
Aviation Medical Center had the
responsibility to approve the final decision.
1.17.1.7 Waived item
The application for waived item of an examinee in accordance with the content
of Chapter
5 of "Aviator's Physical Examination Standards" would be approved after
the examination process of the physical examination doctor or some specific medical
examination. The waiver would be accepted while the enriched experience of the
aviator could compensate the said waiver without jeopardizing the aviation safety. It
should be treated as a special case and to be approved by CAA.
There was no waiver item on the physical examination certificate of the captain
involved in this incident.
1.17.1.8
Issuance of physical examination certificate
After a successful physical examination, the result was submitted to CAA for
the signature of the Director General to issue the physical examination certificate.
1.17.2 The Flight Operations Section of CKS International
Airport
The Flight Operations Section of CKS Airport was located in Terminal 1, next
to A9 parking bay.
The Flight Operations Section of CKS Airport organized of totaling 20 people
with a section chief, 15 section staffs working in three shifts and 4 staffs working in
office hour. Each shift used to have of 4 staffs and would become 5 staffs after the
Terminal 2 of CKS Airport established.
Personnel at Flight Operations Section took the training courses prepared by
their own instructors.
held by Aviation Training Academy of CAA.
The annual re-current training and joint operation drills were
25

For emergency notice on aircraft accidents, the agencies in the airport
communicated one another by the direct line of telephone. In case of emergency,
the
control
tower would ring the alarm.
Regarding the duty assignment in case of on-airport aircraft accident, the
Director of local Airport would be the
Commander-In-Chief; the two Deputy
Dire ctors of local Airport and the Deputy Director
of Airport Police Station were the
Deputy Commanders-In-Chief. The Flight Operations Section chief was the on-scene
Commander.
As of off-airport aircraft accident,
there was no duty assignment except the
following description from the emergency response handbook: "The local governor or
his( her) designated proxy should become
responsible with the full help from the
local airport ".
1.1 7.3 CAL's Asian Dispatch Center
under Joint Management
Division
CAL's Asian Dispatch
Center was responsible for aircraft dispatching,
movement monitoring and the communication
with the operating aircrafts. For
contacts with aircraft within 200 nautical miles from the airport, they used the leased
131.5 VHF channel from CAA
by voice communication or printer transmission of
ACARS. In the CI-681 incident, the on-duty personnel at Asian Dispatch Center was
not aware of the fact that the first officer was
not allowed to taxi after landing. The
first officer did request for towing in his
communication but did not state that he was
not a llowed to taxi. The first officer did not use any word to express that it was an
emergency condition. Asian
others in emergency.
1.18 Other information
Dispatch Center did not relay the information to the
1.18.1
ICAO emergency classification and description
ICAO's Emergency Manual provided the handling of airport emergency
incidents. In 2.2.2, emergency was defined as (a) aircraft involved (b) aircraft
not
26

involved (c) emergency medical incident and (d) combined incident:
(a) Emergency with aircraft
involved:
(1) Accident—on-airport
aircraft accident
(2) Accident—off-airport aircraft accident
(I) On land
(II) On water
(3) Accident—aircraft
in-flight incident
(I) Severe turbulence
(II) Loss of pressure
(III) Structural failure
(4) Incident—aircraft on ground
(5) Incident—sabotage, including bomb threats
(6) Incident—hijack
(b)
Emergency involving no aircraft:
(1) Fire—Air terminal structure on fire
(2) Sabotage—including bomb threat
(3) Natural disaster
(4) Hazardous materials
(5) Emergency medical service
(c)
Combined incident
(2) Aircraft/structure
(3) Aircraft/fuel facilities
(4) Aircraft/aircraft
In 2.2.3 of the manual, airport emergency zones come in 3 types:
(a)
On/off-airport accidents:
(b) Full emergency: Aircraft approaching airport involving potential
accident.
(c) Local standby: Aircraft approaching airport involving
accident, but with possible
safe landing.
In chapter 4 of the manual, there were 10 types of emergency cases. Duties and
operation procedures of the agencies involved (Air Traffic, Fire fighting, Security,
Airport Administration, Medical Service, Hospitals, Airlines, Government
Agencies and Public Relations). The 10 accidents were given as follows:
(1) On-airport accidents
(2) Off-airport accidents
(3) Full Emergency
(4) Local Stand by
(5) Non-aircraft accident airport emergency measures
(6)
Illegal intervention to flight
27

(8) Hazardous materials
(9) Disasters
(10) Aircraft in water
Chapter 2
Analysis
The pilot and co-pilot of this flight who had the health Certificate issued by the
Aviation Medical Center of CAA. During this flight, the pilot became accidentally
incapacitated and resulted in death.
The Aviation Medical Center of CAA was responsible for the physical examination of
all the flight crew. The physical examination would greatly influence the flight safety.
The co-pilot, with the assistance of the Air Traffic Controller was able to land the
aircraft safely although emergency
support on the ground was not immediate. The
parking bay prepared was not taken into
account for emergency medical treatment.
There was no appropriate communication to let the ambulance stand by the door of
the aircraft. The aircraft was arranged to park at a remote bay. It delayed the medical
28

personnel from boarding the aircraft immediately. After landing, the required medical
treatment to the patient was not timely serviced.
2.1 Analysis of the Cause of Death
An autopsy on the internal organs as well as inspection of the pilot’s urine, blood, and
stomach contents were performed by the examiner from the Ministry of Justice, upon
the request of the Tao Yuan District Attorney Office. The examination report of the
cause of death was listed as Appendix 9.
2.1.1 Examination
Visual observation: Upon examination of the dead person’s whole body, no external
injuries were found and the conjunctiva was normal.
There was no bleeding on the
scalp and no bones were broken. However, the upper left part of the coronary artery
was 50% cramped. Valve membrane showed no signs of abnormality. The aorta was
somewhat swollen and there was calcification of the abdominal artery and presence of
ulcers.
Microscopic
observation: Aside from the cramped coronary artery, there was no
special irregularity.
Pathological observation: Acute coronary artery occlusion, with traces of dried plums
found at the tip of the larynx, sudden death occurred, death by natural causes.
Narcotics police found no traces of
toxic elements. Alcohol found in the patient’s
blood,
urine, and stomach contents had a 0.00487% level (W/V), less than 0.002%
and 0.102%, with no other toxic elements. For details, please refer to Appendix 10.
Upon anatomy of the body, it was found that there was serious coronary artery
occlusion and visible sclerosis, calcification, and ulcers of the abdominal aorta. Half-
digested plum was found at the stomach. Some residue of plum was found in the
upper part of the larynx.
2.1.2 Examination Result
The results of the examination of forensic doctor of the Department of Justice
indicated that coronary artery occlusion was the cause of death, death by natural
causes, as detailed in Appendix 9. The Aviation Safety Council had invited the related
airline medical personnel and cardiovascular experts to conduct an in-depth
investigation into the cause of the pilot’s sudden death during the investigation. The
cardiovascular doctor had directly pointed to acute coronary artery occlusion as the
29

main cause of death, thereby becoming the main reason for the incapacity. The plum
residues found in the throat of the pilot was shifted during emergency rescue or the
moving of the pilot. The residue of the plum was not the main cause of his sudden
death.
2.2 Analysis of Physical Examination
2.2.1 The Examination Equipments of CAA
The pilot involved in the incident had undergone physical examinations five times at
the Aviation Medical Center of CAA. Of these examinations, there were three
treadmill EEG examination records. The treadmill was adjustable slope type
equipment and received function test including the synchronization with the simulated
EEG.
2.2.2 EEG Data
The Aviation Medical Center used the “Civil Aviators’ Physical Examination
Handbook” as basis for its handling of the examination affairs. Articles 18, 19, and 20
of Chapter 2 stated the handling procedures and principles for heart murmurs, athletic
EEG irregularities, and arrhythmia.
In each of the EEG examinations of the pilot, no signs of irregularities or no positive
reactions were found. Therefore, no further examination was made to the coronary
artery occlusion and no CAT scan was conducted either. According to medical
statistics, the accuracy rate of EEG in predicting coronary occlusion was 20%; of
athletic EEG was about 50 to 60%; of the cardiovascular sonograms was 70% and of
CAT scans was 95%.
2.2.3 The high number of white blood cell (WBC) to the cause of death
The Aviation Medical Center found out during each time of the physical examination
that the pilot would need a re-examination due to his high number of white blood cell.
The Aviation Medical Center had experienced
twice of the accepting the re-
examination
data of the pilot examined in foreign country agencies. Only one
inspection dated November 25, 1999 recommended that the pilot require having a
special examination to the clinic of orthodontist in Aviation Medical Center to check
the
number of white blood cell. The result was no inflammation and was
recommended to have a further inspection to the cause of high number of white blood
cell. The Aviation Medical Center did not request for further examination or did the
follow-up of this inspection.
30

Both the American Academy of Periodontology and the ROC Academy of
Periodontology had formal documents describing that statistically the direct
relationships
between periodontal infection and cardiac diseases or strokes. They also
pointed out that the risk factor of people who had periodontal infection to have
systemic diseases and cardiac strokes was more than double as compared to people
who did not have periodontal infections. (Reference: “Periodontal Disease As A
Potential Factor for Systemic
Diseases,” Journal of Period ontology, Vol. 69, p. 841-
850
1998.) Furthermore, based on the categorization of periodontal diseases, the
traditional categories were: 1. Gum diseases, 2. Early periodontitis, 3. Mid-level
periodontitis, 4. Serious periodontitis, 5. Recurring periodontitis. If based on the 1989
World Period ontology Congress, there would be eight categories, namely: 1. Gum
diseases, 2. Chronic periodontitis, 3. Invasive periodontitis, 4. Disease
related
periodontitis,
5. Periodontonecrosis, 6. Pus swelling of periodontal structure, 7.
Pathological changes in periodontal make-up, 8. Congenital or acquired periodontal-
related irregularity. (Reference: “Screening and Categorization of Periodonts” Journal
of ROC Academy
of Period ontology, Vol. 3, p. 168 September 2000) This issue
stated
that periodontal infections should not be limited to acute periodontal infections.
Inasmuch as the deceased pilot was diagnosed as having periodontitis in November 8,
1999, the Aviation Medical Center did not have related recommendations. When the
pilot, in the process of the examination, told the center of his periodontal medical
history, the center’s diagnostic result was “non-acute periodontitis, needs to be
pursued further.” The whole thing was based on judgment, without the benefit of
screening or diagnosis; therefore the pilot was not informed that his risk of heart
diseases or cardiac strokes had just gone up.
According
to the final judgment of the cardio-vascular specialist, the high white blood
cell count did not bear any direct relationship to the coronary occlusion.
2.2.4 Impact of high blood fat on the cause of death
Article 22 of Chapter 2 of the “Civil Aviators’ Physical Examination Handbook”
stated very clearly the procedures for examination of high blood fat level, with
cholesterol value in excess of 6 as a threshold level, where, on a case-by-case basis, a
person may be asked to cut down smoking, lose weight, exercise, and go on a low-fat
diet. When cholesterol level exceeded 240, dietary treatment should be recommend by
a dietician.
The doctor of Aviation Medical Center wrote the suggestions for the pilot to watch his
dietary intake as well as having a regular exercise regimen. However, there was no
31

obvious lowering of blood fat levels. There was no record of consultation with the
medical center’s dietician.
The high blood fat condition when combined with several factors such as age, gender,
and smoking would make it a high-risk group of heart disease. In this case, the pilot
had matched the characteristics of the high-risk group. Autopsy of the pilot had
determined that the pilot indeed succumbed to coronary disease.
2.2.5 Comparison of Organizational Structures of the Aviation Medical Center,
International Civil Aviation Organization, and the Federal Aviation
Administration
Distinguishing Feature of the Physical Examination of ICAO described:
The International Civil Aviation Organization made the minimum requirement to
flight safety, in order to make it easier for all countries to implement the procedure.
Moreover, ICAO limited itself to only making physical examination standards on
principle; it completely authorized the flight surgeon of each country to act and decide
on the merits of medical knowledge, with protecting aviation safety as its highest goal.
Presently, the civil aviators’ physical examination standards followed in the country
was
much more stringent than those of ICAO.
Distinguishing Feature of the Physical Examination of FAA described:
The American Federal Aviation Administration designated doctors to conduct
physical examinations of aviation personnel. Because the United States was a big
country, with a large number of aviation personnel, the FAA conducted more than
500,000 physical examinations annually. Consequently, there was no
way to
centralize all the physical examinations, so it was necessary to designate authorized
doctors to conduct these examinations. The number of the designated doctors was
more than 5,000. Some of the doctors had to conduct physical examinations after
undergoing few days training that resulted the inconsistency in the quality of the
physical examinations. The examination doctor had limited examination items to
check by using different equipments. During the physical examinations, the doctor
would ask the examinee to self-describing the health conditions. However, if there
were any concealment of the facts in the statement, there would be a US$ 250,000
fine or jail time of not more than five years. The two sentences even could be jointly
meted out (refer
to Appendix 11 FAA Physical Examination Chart). Individuals who
had
undergone both the FAA physical examination and CAA physical examination
could realize that CAA examination was more stringent than FAA examination. For
32

example, the FAA examination would not require the Category I Pilot to attach the
EEG record in his physical examination. The FAA accepted the 0.0 vision condition
(Should be normal after correction) but the CAA only accepted 0.2 visions. In the past,
many airlines hoped to hire foreign pilots who had the FAA physical examination
certificate,
but were not able to because those pilots did not pass the physical
examination of CAA.
Unlike the FAA, our civil aviation law did not have a rule to punish individuals who
hide their medical histories. It was very difficult to control the history hiding while
the flight surgeon conducted the physical examination by asking the examinees to
express their medical history. Especially in the present time where pilots came from
various parts of the world, or local citizens who came from fields not related to
aviation, the concealment of medical histories was a blind spot during physical
examinations.
2.2.6 Examination of coronary diseases by the Aviation Medical Center
According to the statistics of the Aviation Medical Center, between the years 1987
and 1995, there had been 48 civil pilots, 4 of them were foreign pilots, lost their
physical certificate. It was equivalent to 6.8% per thousand pilots. There were 25% of
the pilots who lost their physical examination certificate were between the age of 40
to 49. There were 65% between the age of 50 to 59 and 10% of other age.
More than 50% of the pilots lost their physical examination certificate had the
problem of coronary conditions. Heart attacks were difficult to predict, thereby having
a major impact to flight safety. Because of flight safety, the doctor conducted regular
physical examinations were looking for signs of coronary conditions to prevent the
unpredictability of heart attacks. The Aviation Medical Center of CAA demanded that
an athletic EEG examination be conducted annually would be a great help in early
detection of coronary diseases. The Aviation Medical Center of CAA also suggested
the examinee to conduct a bypass inspection or a CAT scan as necessary. In addition,
a cardio-vascular ultrasound or a 24-hour EEG examination might also be suggested
as required.
There were no irregularities found in the athletic EEG of the pilot in this incident.
Therefore, no further examination was made to examine the narrow condition of the
coronary artery. The Aviation Medical Center’s examination procedures of the
athletic EEG is shown in Fig. 2.2.6-1
33

Abnormal
Heart Rhythm
Disorder
48 Hours EEG
Normal
Certification
Issued but
need the
follow-up
Fail to Pass
the
Examination
Athletic EEG
Abnormal
Insufficient O2
CAT Scan
Abnormal
Duct By-Pass
Normal
Abnormal
圖 2.2.6-1 The EEG process of Aviation Medical Center
34

Aside from the present procedure of asking for medical histories, the
evaluation of human cardio-vascular system found in clinical examination, tread mill
athletic EEG, by-pass examination should consider to have the 24-hour EEG,
cardiovascular ultrasound, and CAT scanning. For the proper management of the risk
factors in coronary factors, one should refer to the Framingham Scoring System
jointly recommend by the American College of Cardiology and American Heart
Association. (Reference: Assessment of cardiovascular risk by use of multiple-risk-
factor assessment equations, Journal of American College of Cardiology 1999
34:1348-59). One may also consider the evaluation procedures used in Europe
(Reference: Prevention of coronary disease in clinical practice: recommendations of
the second joint task force of European and other societies on coronary prevention,
European Heart Journal 1998 19:1434-503).
2.2.7 Physical Examination Report of Aviation Medical Center
Presently, after the physical examination report and certificate were issued, the pilot
who passed the examination but required to have a further examination, his certificate
would be sent to the airline or the aviation medical doctor to transfer to the certificate
holder. The Aviation Medical Center would not follow-up or analyze the suggestion
they made.
Generally, when aviation medical department of the respective airlines received the
physical examination reports of their pilots, they rarely controlled the suggestion
items or followed up the health improvement of the pilots.
After receiving the physical examination report with suggestions but without
warnings from the doctors or lack of personal health improvement knowledge, it was
very easy for the pilots to ignore the self-improvement to the health.
The pilot in this incident belonged to a high-risk group. For the past three years, his
white blood cell count as well as his blood fat level did not decreased. It was proved
that there was lack of follow-up as well as substantial improvement, the airlines’
management level or medical doctor and the Aviation Medical Center of CAA failed
to require the suggestions to be improved and the pilots who had undergone the
physical examination ignored the suggestions from the medical doctor.
2.3 Airport Emergency Procedures
This section was based on the Airport Service Manual, Airport Emergency Planning
35

DOC-9137 Part 7 recommended by the International Civil Aviation Organization. It
looked into the related procedures for emergency incidents used at Chiang Kai Shek
Airport.
2.3.1 Categorization and Details of CKS Airport Emergency Procedures
According to the categorization and details of emergency cases in chapter
1.18.1 of ICAO documentation, we reviewed the related regulations governing the
CKS Airport emergency responses and found out the inconsistency of the
categorization of emergencies and the procedures described in different procedure
manuals. It made the involved agencies to do the emergency responses their own way
or with no procedure at all. This resulted in the failure of agencies to be effectively
integrated for their operations.
For example, the airport had “Implementation Highlights of CKS Airport to the
Accident or Incident Handling Procedures.” The Chapter 9 of this document
contained the procedures for accidents or incidents happened on and off the airport. If
the accident happened on the airport, it would be categorized as either “Partial
damage of the aircraft after landing ; No fire explosion after landing with no
injuries;Fire and explosion after landing with occupants injured and fatal.” The off
airport accidents were categorized as “aircraft accident on ground” ; “aircraft
accident on sea.”
Implementation Highlights of CKS Airport Aircraft Accident and Incident Handling
Procedures failed to take into account the total emergency accidents procedures and
the local area standby procedures. However, the handbook of the firefighting squad of
the CKS Airport categorized the procedures into “The accidents during takeoff or
landing”;”Request for emergency landing due to special reason”; “The warning
from the aircraft on ground “; ” Fire inside an architectural and fire outside an
architectural” and so forth. This handbook described the handling procedures used by
firefighters, but no sound procedures for the supporting agencies. There were
procedures dealing with natural disasters mentioned in “CKS Airport Typhoon
Precautionary Measures” There were emergency procedures for illegal interference of
flying activities mentioned in “CKS Airport Emergency Responses for Aircraft
Incident Except Hijacking.”
2.3.2 Procedures for Accidents Off the Airport
Section 4.2 of the ICAO Airport Emergency Handbook mentioned the responsibilities
of each unit in the event of an accident off the airport (refer to Appendix 12). Section
3.12 of the handbook mentioned the important role played by the Search and Rescue
Coordination Center in an off the airport accidents, especially when there was no
36

information of the accident site or there was a need for additional search and rescue
equipment on site or near the site. The search and rescue coordination center needed
to contact with the necessary agencies in a quick way. Its responsibilities included
providing aircrafts, helicopters, special search and rescue equipment and team. The
rescue plan should have a specific chapter describing the operations of the search and
rescue coordination center. These operational procedures were not found in the
“Implementation High Lights of CKS Airport Aircraft Accident and Incident Handling
Procedures.”
The “Implementation Highlights of CKS Airport Aircraft Accident and Incident
Handling Procedure” does not also mention the responsibilities and procedures of
each unit involved, which results in the airport having difficulty providing
professional technical assistance for search and rescue, like informing the rescue and
firefighting units of local governments of the aircrafts fire-prone areas, position of
dangerous elements the aircraft is carrying, and the aircraft’s firefighting facilities, etc.
2.3.3 Airline Management Services
The airport management services mentioned in Sections 3.2, 4.1.2 of the ICAO
Emergency Airport Handbook include the airport tower contacting firefighting
agencies and provide basic as well as emergency information as the situation warrants.
Information includes model of the aircraft, fuel volume, location of the accident.
Furthermore, emergency plan should have a standardized method for the tower or
airport management to get in touch with local firefighting agencies and other
appropriate organizations. The initial report should provide graph maps, rendezvous
points, open airport entrance; airport management does not have to handle these
communication functions, but it should designate a group to see to it. Clear
delineation of responsibilities should be done on the initial telephone report to avoid
repetitions. Relevant data can be added over the phone, including the number of
passengers, dangerous goods on board and the names of the flight personnel, and
others. The airport may be declared closed while dealing with the emergency,
although airport management has to make the call as well as register the time the
agencies were contacted and signing up procedure.
The communication team provides the functions stated in the “Implementation
Highlights of CKS Airport Aircraft Accident and Incident Handling Procedure”.
However, it is not mentioned that the communication team also provides basic
information to the support groups, that it should continue to collate materials to repeat
contact as well as register the time the agencies were contacted and signing up
procedure.
37

2.3.4 Firefighting and Rescue Services
Sections 3.3, 4.1.3 of the ICAO Emergency Procedure Handbook mentions that
firefighting and rescue personnel should consider rescuing of individuals as the
ultimate goal. In order to achieve this goal, fires will have to be put out and steps
should be taken so it does not break out again; assistance should also be given to the
people on the aircraft so fast exits can be arranged. It would be better if airport
firefighting personnel or other personnel should have emergency medical training,
because these people are on the frontline and are usually the first people to arrive on
the scene. If the people who immediately respond to the crisis have medical
qualifications, it can significantly reduce the death toll. Only firefighting personnel
wearing fire protection suits and equipment will be allowed to get close to the aircraft.
These personnel should suit up 100 meters outside of any point from the aircraft or
from the oil dumping point. Firefighting personnel and vehicles should:
Be shown the fastest way into the site by airport management people.
Inform suggested mutual support firefighting agencies about:
Rendezvous point
Staging area
Labor and Equipment Support Needs
Other materials
Immediately establish temporary easily identifiable command center, until the
command center of the airline management department is already up and operational.
Similar operational details and standardized responsibilities were not included in the
“Implementation Highlights of CKS Airport Aircraft Accident and Incident Handling
Procedure.”
2.3.5 Warning Service
Section 3.4 of the ICAO Airport Emergency Procedure Handbook states that police
personnel should reach the accident site on the fastest time possible, close up the site,
and wait until the police from the station with jurisdiction arrives at the scene to take
over. The plan should take into account local police, the military and other
government officials to be able to provide timely and efficient assistance. At the same
time, they should immediately allow for unimpeded entrances and exits as well as
smooth roads to allow emergency vehicles to come through. Bystanders should be
barred from the scene, to prevent damaging the accident site and preserving the
evidence useful to the investigation. Support plan should consider all possible police
agencies including county police, the MP’s, customs police, and others. Police
38

personnel should, at every checkpoint, inspect every rescue personnel entering the
accident site. Identity cards should be provided and given to each individual involved
in the incident. A lot of cases show that support vehicles like firefighting trucks
cannot directly enter the accident site because of venue problems. Consequently,
rendezvous points should be established, in order to minimize traffic congestion,
which can interfere with operations at the accident site. Police should also be on hand
to control the vehicular flow at these points.
The process of the “Implementation Highlights of CKS Airport Aircraft Accident and
Incident Handling Procedure” does not include making the nearby entrances and exits
as well as the roads as unimpeded as possible, the making of identity cards as well as
setting up checkpoints and review areas, establishing rendezvous points and
coordinating with the police.
2.3.6 Airline Company
Section 3.8, 4.1.8.2 of the ICAO Airport Emergency Procedure Handbook states that
in the plan, the airline company has to provide information on the aircraft involved in
the incident such as the passengers’ manifest, jet fuel volume, dangerous goods
(including liquid gas, flammable liquids, oxygen tanks, toxins, communicable and
radioactive elements) and other basic information to the site commander and agencies
that need to know. At the same time, it is necessary to arrange for those unhurt to
proceed with their trip and to contact the relatives of those who are injured or dead.
The plan should designate an airline company to handle transit as well as private,
military, and other non-users of the airport.
The process in the “Implementation Highlights of CKS Airport Aircraft Accident and
Incident Handling Procedure” does not include immediately providing information on
the aircraft such as the passengers’ manifest, jet fuel volume, dangerous goods, and
other basic information to the site commander and agencies that need to know. There
are also no provisions as to how the airline company will handle transit, private,
military, and other non-users of the airport in an emergency situation.
2.3.7 Transport Support
Section 3.8 of the ICAO Airport Emergency Procedure Handbook states that during
emergency rescue operations in an accident, search and rescue missions can be carried
out, the transport of personnel, wreckages, and supplementary transports. The use of
public utility vehicles, rented vehicles, trucks, meal vans should be included in the
plan. Lead vehicle should be easy to identify and should be equipped with two-way
radios. From the waiting area to the accident site, the lead vehicle should not be
hampered by the operations of other aircrafts. There should also be provisions for
39

vehicles that can travel on water and marshes as well as other special vehicles.
The process in the “Implementation Highlights of CKS Airport Aircraft Accident and
Incident Handling Procedure” is for the ground crew to provide transport support,
which does not include taking into account the abovementioned lead vehicle as well
as the waiting areas. It also does not include detailed plans for airport capabilities
investigation and allocation procedures.
2.3.8 Communication Coordination
Section 12.3.3 of the ICAO Airport Emergency Procedure Handbook states that the
frequency used by the command center should be able to be connected directly to the
aircraft as well as ground control personnel and that there should be earphones to
reduce interference. Section 4.3 of the ICAO Firefighting and Rescue Handbook
states that communication between firefighting; command and cockpit should be
provided during special incidents, especially situations involving the wheels of the
aircraft or the safety exits when the aircraft is in motion. (Chapter 12 of the ICAO
Airport Emergency Procedure Handbook deals on communication planning, please
see Appendix 13)
The “Implementation Highlights of CKS Airport Aircraft Accident and Incident
Handling Procedure” states that when an accident occurs, the communication team
shall provide wireless handheld radios to the different working teams, for overall
command to be better. When the incident with this aircraft occurred, the
communication between all the units and the major players was very complicated. It
was necessary to examine further the whole working structure and to include the
communication equipment as well frequency planning into the emergency procedures.
CKS Airport has not planned the emergency wireless communication between the
aircraft and command center.
2.3.9 Telephone Number for Notification
Section 8.1 of the ICAO Airport Emergency Procedure Handbook stated that each unit
should develop a telephone log for different emergency situations. CKS Airport had
not set up telephone log for different situations that would result in difficult to
accurately to choose the right unit be notified.
2.3.10 Airport medical and rescue procedures
2.3.10.1 Airport medical and rescue procedures and arrangements
Section 1.1.9 of the ICAO Airport Emergency Procedure Handbook states that
rescuing the victims and stabilizing their conditions should be taken into account.
Hence, it has declared that speed and skill of medical rescue so of paramount
importance and that standardization and regular simulation are necessary. In addition,
40

Section 3.6.1 of the ICAO Airport Emergency Procedure Handbook states that the
purpose of medical services is to provide categorization injury examination,
emergency and medical treatment:
Reduce the risk of death of heavily injured individual
Ameliorate suffering
Transport the wounded to appropriate medical institution
CKS Airport has not set airport medical rescue procedures in either the
“Implementation Highlights of CKS Airport Aircraft Accident and Incident Handling
Procedure” as well as emergency medical rescue procedure for a solitary case. There
is only the procedure for immigration and custom process for seriously ill passengers,
which cannot standardize the medical rescue emergency responses and techniques of
different situations.
Section 4.1.6 of the ICAO Airport Emergency Procedure Handbook states that the
following should be included as medical services during accidents:
Ensure that support and ambulance groups have been informed of the waiting area or
other staging areas.
Organize injury categorization, handling of the wounded and the dead as well as
arrange for vehicular transport.
Work together with transport personnel to control and ensure the flow of injured
individuals; assign injured individuals to the appropriate hospitals.
Write out a list of wounded and dead individuals, including first and last names as
well as final destination.
Coordinate airline companies to transport those who are not injured to areas
designated.
Provide medical evaluation of passengers who need emergency assistance as well as
those uninjured.
Arrange for additional medical equipment, if necessary.
Work with police agencies to handle matters pertaining to dead individuals.
The “Implementation Highlights of CKS Airport Aircraft Accident and Incident
Handling Procedure” has designated that Min Shen Hospital should establish a
medical team at the accident site, coordinate with command to support medical units
and to examine and categorize injuries and sending the injured to the appropriate
hospital. However, it has not standardized the responsibilities of the medical team
41

during an emergency situation as well as the details of the operation.
2.3.10.2 Transport and handling procedures for medical and rescue
capabilities
Section 3.6.4 of the ICAO Airport Emergency Procedure Handbook states that
emergency plans should include provisions for transporting medical services,
equipment, and personnel to the accident site by air, land, and sea. In terms of
procedures, CKS Airport has not planned the transport of the abovementioned medical
capabilities.
Section 3.6.5 of the ICAO Airport Emergency Procedure Handbook enumerates the
following responsibilities of the medical transport personnel:
Report site situation to hospital and medical personnel.
Send patients needing special treatment to appropriate hospitals for treatment.
Record the names of individuals transported, the number of people transported, when
they reach the hospital and the state of the wounded.
Call ahead for the hospital to prepare while the patients are on the way.
Continue to coordinate with the hospital, the ambulance, senior emergency rescue
personnel, and site commander.
The CKS Airport has not seen any procedure standardizing the responsibilities of
medical transport personnel and has not planned communication and connection
methods for medical coordinators and the site commander as well as any of the
vehicular transports.
2.3.10.3 Organizational plan for mental hygiene
Section 3.19 of the ICAO Airport Emergency Procedure Handbook mentions
emergency response plans including local psychological teams providing counseling
services to survivors, witnesses and rescue personnel. CKS Airport has not included
support and operations of local psychological teams in the emergency procedures.
2.3.10.4 Medical training procedures for standard firefighter and rescue
personnel
Section 3.3.2 of the ICAO Airport Emergency Procedure Handbook mentions that if
the conditions of heavily injured individuals cannot be stabilized in a short time,
which may lead to death, the firefighting and rescue personnel or other personnel
should have better medical training, because these are the people who are on the
42

escue frontlines and who enter the accident site first. If personnel who respond to the
call has medical and rescue experience, it may reduce the number of casualties.
Although CKS Airport has already started EMTI training of first line firefighting and
rescue personnel, this function has not been mentioned in the emergency response
procedures.
2.3.10.5 Hospital Spread Plan
Section 3.7 of the ICAO Airport Emergency Procedure Handbook states that hospitals
should have an emergency plan for accidents. This would ensure that the hospital
would be able to provide the site with a medical team. Moreover, hospitals should
have the capability of handling airline incidents in the form of qualified personnel and
appropriate equipment and facilities. The emergency plan should also include a form
listing all the hospitals in the vicinity and further categorize special injuries such
burns, and not to use up the resources of the nearby hospitals.
4.1.7 of the ICAO Airport Emergency Procedure Handbook states that designated
hospitals complete the following steps:
Transport medical doctors as well as a medical team to deal with external injuries to
the site of the incident as soon as notification is received.
Provide medical services when the injured reaches the treatment area.
Ensure that when emergencies occur, appropriate doctors, nurses, operation facilities,
psychiatric treatment unit, surgical team, and blood bags are fully prepared.
A look at the CKS Airport medical rescue support group and capabilities’ form of the
“Implementation Highlights of CKS Airport Aircraft Accident and Incident Handling
Procedure” does not list the special capabilities of each hospital to be provided to the
medical coordinators as reference when assigning the wounded to hospitals. Support
agreements signed with the hospitals fail to list their capabilities and operation
procedures during emergency situations.
2.3.10.6 Categorization and care of injuries
Chapter 9 of the ICAO Airport Emergency Procedure Handbook states the principle
by which injury examinations are categorized, standardized injury identity card and its
uses, care principle of similar categories, and a detailed operation procedure for the
control of injuries. The “Implementation Highlights of CKS Airport Aircraft Accident
and Incident Handling Procedure” marks the aircraft failure treatment rescue map;
wound list (injury examination form) yet does not include a detailed standard
procedure (see Appendix 14).
43

2.3.11 Graphical illustrations of the airport and the suburbs
Section 7.1 of the ICAO Airport Emergency Procedure Handbook states that the
emergency center should provide the tower, firefighting station, firefighting/rescue
vehicles as well as all vehicles carrying support groups with graph maps of the airport
and the outlying areas. It must provide two types of graph maps: 2.3.11-1 describes
the airport roads and all other roads leading to the outside, water supply locations,
waiting points, and staging areas; 2.3.11-2 shows at least 8 km. of land around the
airport, which includes its topography, its road systems, hospital locations, materials,
waiting points, and other information. The hospitals shown in the graph maps must
also show the number of beds that can be utilized, fields of specialization, manpower,
and other information.
Fig. 2.3.11-1 First ICAO Graph Map of the Airport and Off-Airport Areas
44

Fig. 2.3.11-2 Second ICAO Graph Map of the Airport and off-Airport Areas
A look at the CKS Airport medical rescue support group and capabilities’ form of the
“Implementation Highlights of CKS Airport Aircraft Accident and Incident Handling
Procedure”
described that its graph map did not show the abovementioned water
supply locations, preplanned waiting points, and staging areas, at least 8 km. of land
around the airport, which included its topography, its road systems, hospital locations,
materials, waiting points, and other information. The hospitals shown in the graph
maps might also show the number of beds that could be utilized, fields of
specialization, manpower, and other information.
2.4 Implementation of airport emergency procedures
2.4.1 Transmission of
pilot’s incapacitation
According to cockpit voice records, at 0815 the
co-pilot discovered that the pilot’s
right cheek was trembling and his entire body was leaning towards more to the left,
the face was upturned, the eyes under the sunglasses were slightly opened, breathing
was heavy. At 0816-0817, the copilot communicated with Taipei Area Control Center
to request for return to Taipei, saying that the pilot is incapacitated and requesting that
an ambulance be placed on standby. According to the ground communication records
of area control
center/CKS parking bay/CKS tower/CKS aviation services (thereafter
simply
referred to “ground communication records” as in Appendix 5), at 0817, the
Taipei Area Control Center informed CKS tower CI681 has a sick passenger onboard,
that the aircraft was returning to Taipei and that there was request for an ambulance to
45

standby. At 0818, the tower informed airline service crew of the same news. Because
the
Taipei Area Control Center delivered the wrong information to the tower as and in
turn, to the aviation service crew, OK area control center misunderstood the request of
the co-pilot.
It was until 0825 that China Airlines (Asian Dispatch
Center) informed the CKS
Airport
aviation services crew it has been confirmed that it was the pilot who lost
consciousness. It was only at that point in time that the CKS aviation service crew and
the airport central control center notified the units to start firefighting and search and
rescue
proceedings. The incapacitation of the pilot and the aircraft having to return to
base poses a very big potential threat. With the transmission of faulty information,
then later to be modified, time needed to prepare and adapt to the situation was
severely reduced.
2.4.2
Announcement of emergency situation
At 0816, the co-pilot found out that the chief pilot was incapacitated and used the
word “Incapacity” in informing airport management personnel. At 0831, because
there were other aircrafts, which
have requested “Priority,” nobody knew that the
aircraft
had an emergency situation until it landed. Based on Chapter 9 Section 9-1-1
of the Aviation Control Procedures, the decision for emergency situations are as
follows:
Emergency situations may be perilous or urgent in nature, the definition of which is
included in the pilot/ control personnel dictionary. (Emergency situation may refer to
perilous or urgent)
b. When a pilot encounters
a perilous situation, he/she should use the word
“MAYDAY” in the initial radio communication
to signify that there is an emergency
situation, ideally repeating it three times. When the situation is urgent, the word to use
is “PAN-PAN,” again following the same process.
c. If neither “MAYDAY” nor “PAN-PAN” is used, but the control personnel suspects
that this situation may turn into something urgent or perilous, he may act accordingly.
The Flight Safety Foundation published the Airport Operation Magazine Vol. 26, No.3
in March-April 2000. Said magazine offers some standard language that aviation
personnel
can use when announcing any emergency situation. (See Appendix 19)
Chapter 14 of China Airlines’ aviation handbook states that radio communication
46

procedure during an emergency situation is “MAYDAY” for perilous situations and
“PAN-PAN” for urgent situations.
Only Chapter 3 of China Airlines’ aviation handbook on the handling procedures of
personnel incapacitation as a medical emergency and Chapter 14 on radio
communication procedures during emergency situations do not state what the
conditions are for announcing a perilous or urgent emergency situation. According to
aviation control procedures, the incapacity of the pilot constituted an emergency
situation;
however, the co-pilot did not inform airport management personnel or Asian
Dispatch Center personnel that this situation was an emergency situation, which
affected the procedure.
2.4.3 Handling of Full Emergency Incidents
Because the pilot was incapacitated, the co-pilot landed the aircraft, which was very
dangerous. In the categorization of emergency situation by the International Civil
Aviation Organization, this incident should fall under Full Emergency. When the
aircraft landed prematurely, there was a risk of failure, the level barely at the solution
procedure at the time of the incident. Only because it did not standardize emergency
procedure for such situations and categorization of the incident was
procedure
for communication or for each unit was not comprehensive.
standby by the runway, to pull the aircraft to the parking
bay.
different, the
2.4.4 Transmission of request for ground towing car and read back procedures
According to the cockpit communication records, shortly after the co-pilot requested
for a return to base form the Taipei Area Control Center, the co-pilot told the Asian
Dispatch Center of China Airlines that the pilot has lost consciousness and that he was
requesting that ground support prepare a towing car to be on standby on the runway at
0821. (At 0821:36, the co-pilot said to the Asian Dispatch Center, “681 return to
Taipei. The pilot has lost consciousness. I am now returning to land in Taipei. Request
tow car to be on standby on the runway. I don’t want to taxi the aircraft…” In order to
ensure taxi safety, the flight personnel may not taxi the aircraft alone, according to
company policy. The co-pilot pointed out that he needed the towing car to be on
Interviews conducted with the Asian Dispatch Center people working during that shift
reveal that they did not hear the co-pilot request for a towing car to be on standby by
the runway. Consequently, when the aircraft landed safely at about 0850, there was no
towing car for support. It was only until 0852 when tower asked the co-pilot if he
needed a towing car for assistance and reminded the co-pilot to ask the Asian
Dispatch Center on how it is progressing with the towing car. It was only then that the
47

Asian Dispatch Center asked for a towing car from the China Airlines’ aircraft
services and Tao Yuan Logistics Center. The towing car requested form the Tao Yuan
Logistics Center arrived at 0901 and at 0904 started towing the aircraft.
The only rule known and followed by all in land-to-air communication process is the
read back procedure, which confirms transmitted materials on both sides to make sure
there are no misinterpretations. If we take a look at the related information on land-to-
air communication found in the China Airlines’ airline services handbook (Chapter
13), the medical emergency situation of flight safety and safety management (Chapter
3), and flight assignment (Chapter 5) and other chapters related to emergency
responses, we see that there is no read back procedure to ensure that information
during an emergency situation can be relayed accurately. At the same time, because of
the miscommunication on the towing car
that occurred between the co-pilot and the
Asian
Dispatch Center personnel, it resulted in the co-pilot requesting for a towing car
to be on standby while he was still up in the air at 0821, and the towing car coming in
nine minutes later after the aircraft landed at 0852.
2.4.5 Transmission of runway designation
According to the cockpit communication records, at 0823, the co-pilot first contacted
the Taipei Area Control Center East Division requesting to land on the Runway 05
Left. At
0824, the co-pilot first contacted the Taipei Area Control Center West
Division
requesting to land on the Runway 05 Left. With confirmation form the East
Division, the co-pilot requested for Priority Landing, citing a sick passenger as reason.
At 0836 the Taipei Area Control Center West Division requested that landing be made
on Runway 06. The co-pilot immediately made a repeat request and was granted
permission that Runway 05L be used. The request for a specific runway and the
granting of the permission were repeated three times. There were discrepancies in the
transmission of information between the co-pilot and aviation control personnel.
According to the record of the firefighting crew, at 0825, airport control requested that
the airport ambulance be on standby at Parking bay 608. At 0830, the firefighting
crew instructed the firefighting
truck and the ambulance to go Runway 06. They
completed
all preparations by 0835. Firefighting team records show that at 0842, the
tower informed the firefighting team to transfer to Runway 05L, preparations were
complete at 0845. Understanding of the information as well as the transmission error
resulted in the ground response time being sharply reduced, affecting the overall
affectivity of the emergency responses.
2.4.6 Training of medical coordinator
Section 3.6.3 of the ICAO Airport Emergency response Handbook speaks about the
48

operations procedure that the medical coordinator would have to implement in order
to be able to control the medical situation in the accident site. This medical
coordinator should be an airport medical personnel and he can designate as temporary
coordinator one of the airport paramedics who can be on the site the soonest time
possible.
The Chiang Kai Shek Airport has not set any medical operation procedure for
emergency incidents. However, the “Implementation Highlights of CKS Airport
Aircraft Accident and Incident Handling Procedure” has designated personnel from
the airport clinical department of Min Shen Hospital as medical coordinator. This
medical coordinator should assign doctors, nurses, ambulances, to the accident site
and establish an emergency injury examination center, coordinate command support
agency (medical institutions belonging to the emergency medical rescue network of
the Tao Yuan area), examine and categorize injuries, and send the injured to the
appropriate hospitals.
After the incident, the medical coordinator we interviewed said that he never read
through the “Implementation Highlights of CKS Airport Aircraft Accident and
Incident Handling Procedure,” and has never received training on how to set up an
emergency injury examination center, coordinate command support, send the injured
to appropriate hospitals and other responsibilities.
Looking at the “Implementation Highlights of CKS Airport Aircraft Accident and
Incident Handling Procedure,” it does not designate one of the airport emergency
personnel as temporary medical coordinator. Whoever the airport designates as the
medical coordinator, any one of the participating medical personnel should be familiar
with emergency medical procedures.
2.4.7 Designation of the aircraft parking bay
081748 Taipei Area Control
Center informed the tower that CI681 that a sick
passenger is requesting that an airport ambulance be on standby. 081823 Tower
informed
the airline services team on shift on parking bay 681 to return to base, that
there is a sick passenger, and that the aircraft was requesting a specific parking bay.
After conferring
with the Tao Yuan prosecution office, 082339 airline service
department head briefed the tower to assign parking Bay 608 BAY ferry parking bay.
Based on interviews with airline services personnel, at this stage, parking Bay 608
was selected because the emergency personnel believe that the passenger was in dire
need of emergency help and the other parking bays were already full; moreover,
parking Bay 608 was closer to runway 06. The “Important Points in the CKS Airport
49

ferry of goods and passengers in the domestic lines and overnight adjustment of
aircraft position” as well as the “Management Regulations of CKS Airport Ferry
Parking bay Procedures” did not show that aircrafts returning to base should be
limited to stopping at ferry parking bays. 082510-airport service department
confirmed that the pilot has lost consciousness; the only inadequacy was that after the
aircraft landed, the company refused to allow the co-pilot to taxi it. At 0826, tower
informed airport services department that said aircraft had already landed at Runway
06, the distance of which was closer to Parking Bay 608, resulting in the airport
services crew not being able to change to the parking bay where the aircraft was
closer. According to the firefighting team, at 0842, the tower informed the firefighting
team that the aircraft would be landing on Runway 05L instead, but when the aircraft
started emergency landing procedures, the airport service crew was not any closer to
the landing parking bay to shorten the time
because
of the change.
in sending the injured to the hospital
2.4.8 Airport Emergency Rescue Procedures and the Command of Accident Site
The chief of Flight Operations Section of Chiang Kai Shek Airport was the on-site
commander.
The ground-to-ground communication indicated that at 0818 the Flight Operations
Section of CKS Airport received instruction from the tower that a sick passenger was
carried on board. At 0823:39 the Flight Operations Section of CKS Airport informed
the tower that the aircraft was assigned at transit-Bay 608. Records of the firefighting
department
showed that at 0825 the airport central control center informed the airport
ambulance
to go on standby at parking Bay 608. Till at 0830, it was confirmed that a
pilot was incapacitated on board. At 0842 the ambulance was asked to change the
standby position to the side of the runway. At 0920, the aircraft was towed to parking
Bay 608, with the ambulance trailing behind the aircraft.
The medical coordinator designated by the airport (from the airport clinical
department of Min Shen Hospital) was informed by China Airlines at 0830 for
emergency. At 0840, China Airlines staff escorted the coordinator to Bay 608 for
standby. The medical personnel stayed at Bay 608 until the aircraft towed in. The
coordinator based on the “Implementation
Highlights of the Procedures of CKS
Airport
Accident Handling,” the designated medical coordinator should be informed
by the central control center and controlled by the Accident Site Commander, Chief of
Flight Operations Section” However, the site commander was not able to directly
communicate with the medical coordinator.
At 0822, the Asian Dispatch Center of China Airlines was informed that the pilot had
50

lost consciousness. At 0835, it informed the Tao Yuan Ground Service Company that
a passenger had lost consciousness and would need supporting equipment to hoist and
lower the person. At 0840, the stretcher and the host and lower equipment were
already on standby at parking Bay 608. Until 0920 the aircraft was towed to parking
Bay 608, where the equipment awaited the patient. The site commander did not
command the stretcher as well as the hoist and lower equipment to standby on the
runway
and to assist the medical personnel to immediately escort the patient down the
aircraft.
At approximately 0852, the aircraft landed and stopped
at the runway, the site
commander did not communicate with the cockpit directly
through radio. The cockpit
and ground communication lines, those capable of communicating
with the cockpit,
were with the ground crew who came to the side of the aircraft together with the
towing car. The site commander had to go through the tower to communicate with the
cockpit and the co-pilot had no idea of what kind of emergency support the airport
could provide. The commanding instructions and information of the site could not be
transmitted
clearly and timely.
The
site commander was able to contact firefighting and medical units and put them
on standby. After the aircraft came to a stop, the site commander was, because of poor
communication with the cockpit, not able to know the reason why the aircraft was
not
able to taxi to the aircraft-parking bay. He did not command a stretcher and the
medical
coordinator (medical personnel from the airport clinical division of Min Shen
Hospital) to go to the runway with the ambulance to provide support services by
carrying the patient on a stretcher down to the aircraft
and rushing him to the hospital.
The
site commander was not in a position to fully take position to initiate the real-
time rescue immediately after the aircraft landed Moreover; such similar medical
emergency procedures
were not seen on the related Airport Emergency Response
Manual.
51

3.1 Findings
Chapter 3
Conclusions
1. The
captain held a physical certificate and a certificate of the aircraft rating issued
by
Civil Aeronautics Administration (CAA). The physical certificate showed no
specific
restrictions or any record of waiver. (1.5.1)
2.
According to the data of his heavy weight, age, hyper lipidemia and smoking habit
cardiac
patient. (1.13.3,1.13.4)
3. The incapacitated pilot made no remarkable improvement to the suggestions
of
the physical examination doctors.(1.13.3)
4.
6.
7.
in his physical examination record, the pilot was grouping to a high potential
There was no pilot’s recent medical history dated before his coming to work in
Taiwan.
5. The track cardiograph of the pilot physical examination record showed no
symptoms of myocardial infarct. The Aviation Medical Center did not have to
conduct the follow-ups in accordance with the Procedures of Physical
Examination of CAA. (1.13.5,2.2.6)
The pilot’s working hours, flying hours, and Rest time were totally in
accordance with CAA laws. The flight crew who flew with the said pilot in one
or two days before the incident said
that he did not exhibit any irregularity at
work. (1.5.2)
The medication the captain carried with him showed no toxic ingredients or any
cardiac-healing medicaments. (2.1.1)
8.
The cause of death of the pilot was coronary artery occlusion, i.e., a natural
death. (2.1.2)
52

9.
10.
When the pilot incapacitation happened, the first officer proceeded with the
11.
system at CKS International Airport.
However, the first officer failed to use
12.
The doctor on board performed first aid to the captain and found that the captain
13.
The first officer conducted the flight with autopilot. The weather of the day was
fair and the aircraft was in airworthiness condition. Before the incident, no flight
crew had extra workload and the captain was under regular pressure of work.
(1.1,1.6.2)
airlines' incapacitation procedures and landed the aircraft safely with auto-land
emergency phraseology to report the serious incident. (1.1,1.15.2,1.15.6)
As the captain experienced the incapacitation, the flight attendants that entered
into the cockpit had good cooperation with copilot and kept performing cardio
pulmonary resuscitation (CPR) to the captain. (1.15.3)
had incontinence of urine, mydriasis, no heartbeat and pulse reaction. (1.15.3)
The CKS International Airport provided medical personnel and facilities and
maintained a medical cooperative contract with MinShen Hospital. The
CKS
Airport also provided procedures for seriously ill passengers to quickly pass the
immigration. However, there were no medical treatment operation procedures
established in CKS Airport. (1.13)
14. In the "Civil Aircraft Accident Procedure Highlights" of the CKS International
Airport, it stipulated that medical service in airport was the responsibility of the
contracted Mingsheng Hospital. However, the said
Highlights failed to describe
the duties and detailed procedures of the medical service team. (1.13,2.3.10.1)
15. The air traffic controllers at Taipei Area Control Center failed to understand the
message of incapacitation
sent by the first officer of the aircraft. They relayed a
wrong message of a seriously ill passenger to the airport authority. Again, the
first officer made requests twice to land on Runway 05-Left, however, the air
traffic controllers answered runway in use 06. It was observed that the air traffic
controllers failed to comprehend the message sent by the first officer and that
severely affecting the following emergency operations on ground. (1.15.6,
2.4.1,2.4.5)
53

16. The CKS airport authority
failed to offer the nearest parking bay available for the
emergency response servicing.
(2.4.7)
17. CAL's
Asian Dispatch Center personnel failed to fully communicate with the first
officer and keep close contact
with the CKS International Airport authority.
CAL's Asian Dispatch Center personnel failed to response properly for saving the
time to comply the request of the officer to call towing vehicles to stand by the
runway. It made
the aircraft wait for towing vehicles for as long as 9 minutes
(0852-0901) on the runway.
(1.15.6,1.15.6.1,2.4.3,2.4.4)
18. The commanding
vehicle at the scene had no two-way radio for communications
with the aircraft that made it impossible to know immediately of those emergency
responses such as that the first officer was not authorized to taxi, the condition of
the sick person and the intention of the aircraft commander. (1.15.6.2,2.3.8)
19. CKS Airport had the “Implementation Highlights of CKS Airport Accident and
Incident Handling Procedure”, the “Civil Aviation Accident Notification
Procedures,” the “CKS Airport Transit Procedure for Emergency Sick
Passengers,” and the” Firefighting Operation Handbook”. However, there was no
such “ Full Emergency Operation Procedures” as recommended by International
Civil Aviation Organization. (1.18.1,2.4.3,2.4.6)
20. The aircraft landed and came to a completely stop at 0852. The incapacitated pilot
was carried to the ambulance at 0936. The whole emergency process took 44
minutes. (2.3.4,2.3.10.1)
3.2 Probable Causes and Contributing
Factors
Probable Causes
The pilot’s natural death was caused by heart rhythm disorder that was triggered
by acute cardiac artery occlusion.
Contributing Factors
54

1. There were no follow-up actions to further remind the pilot who
belonged to the hig h-risk coronary disease group.
2. According to the pilot’s physical examination records, the pilot made no
signs of substantial improvements to his health.
55

Chapter 4
Recommendation
4.1 Interim Flight Safety Bulletin
The
Aviation Safety Council has already issued an Interim Flight Safety Bulletin
(ASC-IFSB-89-05-1) dated May 19, 2000 as listed in Appendix 15.
4.2 Recommendations
To China Airlines
1. To require the pilots to make substantial progress to the suggestions from
their medical
examination doctors (ASC-ASR-00-12-011)
2. To refer to the FRAMINGHAM HEART STUDY and other systems in
evalu ating whether the pilot belongs to a high-risk group of potential victims
of cardiovascular
diseases and in making recommendations on how to
maintain good
health. (ASC-ASR-00-12-012)
3. When hiring new pilots, the airlines should request for their recent medical
histories for
the aviation medical examiner’s reference and follow-up.
(ASC-ASR-00-12-013)
4. In case of emergency, the standard phraseology should be used in the
communication between pilot, air traffic controller or relevant personnel.
(ASC-ASR-00-12-014)
5. To enhance the ground personnel’s emergency response training and
communication with the airport authorities. (ASC-ASR-00-12-015)
To Civil Aeronautics Administration, Ministry of Transportation
56

1. To require the physical examination
agencies to provide follow-
up and controlling regulations
over the high risky pilots suffering
potential cardiac diseases. (ASC-ASR-00-12-016)
2. To require the airlines
or contracted aviation medical agencies to
establish the follow-up system to the suggestions of physical
examiners. (ASC-ASR-00-12-017)
3. To improve the training of Air Traffic Controller in
communication and message understanding during emergency.
(ASC-ASR-00-12-018)
4. To refer to the methods and procedures for emergency responses
of international standard and international airports to review
5.
exhaustively the emergency response plans and procedures used
presently by our airports. In addition, to establish guidelines,
providing them to every airport in order to modify their
emergency response plans and procedures. (ASC-ASR-00-12-
019)
To improve the emergency response operational plan, procedure,
and the training of personnel in and out of the accident
site in
emergency medical treatment. (ASC-ASR-00-12-020)
6. To establish the cable and radio communication equipments as
well as the operation procedure for the communication
between
the site commander and the flight crew. (ASC-ASR-00-12-
021)
57

Appendix 1 CVR Transcript
Taiwan Time: Cockpit recorder time is the same as that of the time of
the Taipei Area Control Center
ATC Time: Transcript time is provided by the Flight Operations
Sectio n Control Center,
CAPT : Chi ef Pilot,FO:
Co-pilot, FA: Flight Attendant,WR: West
Control Center,ER: East Control
Center,AREA: Cockpit area
microphone, C1: Taipei Parking bay,C2:
Taipei tower,C3:Taipei
ground control parkin g bay, GND: Towing car Ground Crew, 677:
China Airl ines Flight CI677, OP: China Airlines’ Asian Dispatch
Center
Time By
Contents
8:00:18 WR CI681, proceed direct to TNN, resume own navigation。
8:00:22 CAPT 681 direct to TNN, thank you。
8:07:40 WR CI681, contact Taipei Control 130.6。
8:07:44 CAPT 130.6, Thanks good day, CI681。
8:07:48 WR Good day。
8:07:54 CAPT Taipei, morning, CI681 with you FL310。
8:07:59 ER
CI681, Taipei Control, 10
miles north of TNN, maintain
FL310, and cleared from Parpa direct Kapli, flight plan route。
8:08:08 CAPT Parpa to Kapli, CI681。
Good morning ladies
and gentleman. This is your captain
speaking. On behalf of entire our crew, welcome aboard
China
Airline Airbus Flight 681 from TPE to Hu Chi Min city. Now
we are maintaining our cruise altitude of 31thousand feet,
average ground speed 570 miles per hour. Estimate time arrival
8:08:32 CAPT
Hu Chi Min at morning 0950. There is a one hour time
different between
Taipei and Hu Chi Min Local time is 8
minutes past 7 in the morning.
Weather forecast at Hu Chi Min
airport is 28 degree Centigrade
about 82 degree F. Please enjoy
your flight. Thank you.
8:09:30 FO No change
58

8:09:37 FO Is 30 and 45 for departure?
8:09:41 CAPT Yeah.
8:12:56 CAPT Do you have……………something
8:12:59 FO Yes
8:13:01 FO You want to fly by yourself?
8:13:03 CAPT Oh no.
8:13:09 CAPT This is what we need.
8:13:11 FO Ah?
8:15:19 FO Are you all right?
8:15:22 FO Captain!
8:15:32 FO Please come in
8:15:39 FO Are you all right?
8:15:48 FO Check and see how he is
8:15:54 PR What is happening to him?
8:15:58 PR Are you ok? Captain
8:16:07 PR Captain
8:16:13 FO I am going back to base, ask somebody to come in and help.
8:16:19 PR Can you land?
8:16:20 FO Yes…Yes…Yes…
8:16:21 FA Captain isn’t feeling well?
8:16:22 PR Yes…
8:16:24 FO Taipei Control,
CI681。
8:16:28 ER CI681, go ahead。
8:16:30 FO
CI681, got some problem, we need turning back to Taipei, and
also request ambulance stand by at Taipei。
8:16:39 ER CI681, say again your reason return to Taipei?
The captain incur incapacity, we need ambulance stand by in
8:16:44 FO Taipei, and currently
just passing Parpa 310, we need radar
vector back to Taipei。
8:16:53 ER
CI681, roger, and cleared from present position right turn, turn
right direct to TNN, focus one arrival to TIA, stand by for
descent, over。
8:17:08 FO Roger, right turn direct to TNN,
focus one arrival。
8:17:14 ER CI681, and request ambulance, request how many ambulance?
8:17:21 FO
One ambulance the captain is incapacity, and we need turning
back ambulance one,
one ambulance stand by, please。
8:17:28 ER CI681, roger。
8:17:54 PR How long will it take
8:17:56 FO Approximately.30 minutes
8:17:58 PR Do we dump the fuel for 20, 30 minutes?
8:17:59 FO This lane has not dumped its fuel. We are going to do an
59

overweight landing
8:18:07 PR You need about thirty minutes?
8:18:08 FO
We will try our best to prepare
in thirty minutes, because we
have no time to predict his actions
8:18:12 PR Ok
8:18:16 FO
I have no time to make a broadcast. Please make the broadcast
for
me.
8:18:18 PR Ok, we will use your name; don’t mind us.
8:18:31 PR How can it happen like this?
8:18:32 FO After the takeoff…suddenly…he tried talking and…...
8:18:47 ER CI681, do you prefer to descend now?
8:18:51 FO CI681, Stand by。
8:19:04 PR Do you need my help?
It’s not necessary. This should be ok, thank you. If moving him
8:19:06 FO is inconvenient, please
help him buckle up his harness to
prevent him from falling forward and blocking my way.
8:19:17 PR Do you want me to move him?
8:19:19 FO If you can move him. If not….
8:19:21 PR I can.
8:19:31 FO Close the door. Don’t let the passengers know.
8:19:36 PR Let’s lift him outside. Who is going to help me to lift him?
8:19:43 ER
8:19:50 FO CI681, roger。
8:20:04 FA
CI681, cleared from present position direct to TIA, direct TIA,
over。
Loosen that cart and help me put him…pull the cart over…
pull the cart over and the we will put him…..
8:20:22 FO Try not to bump into my controls
8:20:52 FO
CI681 roger. Frequency change for only five minutes to report
the company。
8:21:00 ER CI681, roger what?
8:21:03 FO Request change frequency for 2 minutes to contact company。
8:21:08 ER
CI681, roger, approved, and cleared descend and maintain
FL290, over。
8:21:13 FO 290, roger, leaving now。
8:21:15 ER Roger。
8:21:19 FO Operation, CI681
8:21:27 FO Operation, CI681
8:21:34 OP 681 Go ahead, Sir
681 Returning to Taipei. The pilot has lost consciousness. I
want to land in Taipei. After landing, please
have the towing
8:21:36 FO car on standby beside the runway. I don’t want to taxi the
aircraft. The situation is a bit hectic,
I don’t
have time to
prepare.
60

8:21:47 OP When do you expect to reach the airport, sir?
8:21:49 FO
We are currently leaving West Harbor, should reach the airport
in about 20 minutes.
8:21:55 OP
Sir, if you have a minute, please tell us the seat number of the
patient so we can tell the transport team.
It’s not the patient, it’s the pilot who is unconscious……We
8:22:00 FO
are turning
back…….. I don’t have time to talk with you
anymore…. Please prepare an ambulance and a towing
car…hat’s all…Thank you.
8:22:07 OP Copy
8:22:09 FO Taipei Control, CI681 back on frequency。
8:22:14 ER
8:22:20 FO
8:22:25 ER CI681, Roger。
8:23:24 FO
CI681, roger, remain this frequency, and proceed direct to TIA,
over。
Present position direct to TIA, and descend passing FL300 to
FL290。
Taipei Control, CI681 reach and maintain FL290.And possible
request long final for runway 05L
8:23:32 ER .7 for further, over。
8:23:39 ER CI681, contact Taipei Control 126.7 for further, over。
8:23:44 FO 126.7, CI681, thank you!
8:23:47 ER You are welcome。
8:23:49 FO Taipei Control, CI681 maintaining FL290。
8:23:53 WR
CI681, Taipei Control, Roger, 30 miles south of Shikang,
descend and maintain FL270。
8:24:00 FO Descend and maintain FL270, CI681。
8:24:04 FO
Taipei Control if possible, 681 request long final for runway
5L。
8:24:09 WR CI681, copy, and do you need fuel dumping?
8:24:13 FO Negative, Airbus unable dumping fuel。
8:24:17 WR Thank you.
8:25:52 WR
CI681, Fly heading 360 for vector to final approach course,
maintain FL270
8:25:59 FO Heading 360,and maintain FL270 CI681
8:27:15 FO Taipei Control, CI681, any chance direct to Karan?
8:27:20 WR CI681,say again your request?
8:27:22 FO Request direct to Karan.
8:27:27 WR You mean the Karan?
8:27:28 FO Yes, affirm.
8:27:30 WR CI681, can you accept direct to "Bravo".
8:27:34 FO Affirmative thank you, direct to "Bravo"
8:27:36 WR Affirmative, direct to "Bravo"
61

8:29:06 WR CI681, descend and maintain FL250
8:29:14 WR CI681, descend and maintain FL250
8:29:19 FO Descend and maintain FL250, CI681, thank you
8:29:23 FA How much more time does the officer need?
8:29:25 FO About twenty minutes.
8:29:26 FA That long!
8:29:27 FO
I’ll try to be as fast as I can, but any faster and there will be
danger to the structure.
8:29:29 FA
You’re going to be in danger. Well, safety should be our
foremost
priority. Any way, the Captain can still be saved.
8:29:35 FO What is his current situation?
It doesn’t look good. If you arrive immediately, there may be
8:29:37 FA hope, but if you come a little later, it may be too late to save
him.
8:29:42 FO Okay.
8:29:44 FA Is there is an ambulance on the ground waiting?
8:29:46 FO Yes…yes…yes
8:29:47 FO Find a… How’s your English, young man?
8:29:51 FA It’s not that good!
Let’s do it this way, please sit at the side. Now…please get the
8:29:52 FO microphone…Are
you familiar with the putting on the
earphones and making contact
with Operations.
8:30:01 FA I’ll be there in a short while.
8:30:09 FO Taipei Control, CI681
I don’t know…He was okay when we took off. I saw after he
8:30:39 FO changed course… I thought
he was blowing something…I
asked him…I saw he was like…snoring.
8:30:49 FA He fell asleep? Or did he lose consciousness?
8:30:51 FO
His eyes were open…I thought he was playing a joke on me.
Afterwards…
8:30:55 FA He scared you.
8:30:56 FO
It was just the feeling…I thought he was playing a joke on. He
plays jokes on me every time we fly together…
8:31:00 WR CI681, traffic 2 O’clock 10 miles south
bound, flight level 240.
8:31:05 FO Say again flight level?
8:31:17 FO
CI681 got the traffic on TCAS, and also approaching FL250,
request priority for landing, and the patient in critical
condition.
8:31:26 WR CI681, roger.
8:31:28 FA OK, what do we do now, sir?
8:31:30 FO Now you help me adjust a bit
8:31:32 WR CI681, no ATC restriction on speed.
8:31:36 FO 681, roger, and maintain FL250
62

8:31:40 FO
You are on the Operation frequency, Asian Dispatch Center
because I can hear what you’re saying at the background.
Talk to Operation.
8:31:48 FA Are you now connected to the Asian Dispatch Center?
8:31:52 FO Yes, tell him that we’ll be there in twenty minutes.
8:31:53 WR CI681, descend and maintain FL 230.
8:31:57 FO Descend and maintain FL230, CI681.
8:32:01 FO Get in contact with the company.
8:32:02 FA Yes…Yes…Yes, you should tell him.
8:32:04 FO OK
8:32:05 FA Do I need press anything? No?
8:32:07 FO You need to press a little bit
8:32:08 FA Which button do I press in front?
8:32:09 FO
Don’t press the others. Don’t press the red button. This one,
press it backwards.
8:32:12 FA Pull it back
8:32:14 FO Pull it inwards
8:32:15 FA
Pull it inwards and it should be okay to talk. Now, get in line
with the Asian Dispatch Center.
8:32:18 FO Pressing forward this way should be okay; it’s safer.
8:32:20 FA Hold this.
8:32:21 FO Press forward then let go.
8:32:23 FA Can this connect to the Asian Dispatch Center
8:32:25 FO Talk to it while you’re pressing it.
8:32:26 FA Asian Dispatch Center
8:32:29 OP Please speak
8:32:31 FA We let go when he speaks, right? Do we let go?
8:32:32 FO Yes.
Asian Dispatch Center, this is the team at 681. Our Captain felt
unwell shortly after takeoff and he has lost consciousness. We
8:32:34 FA have put him on G1 and asked a physician to give him
emergency medical treatment. We shall be landing
at Taipei
Airport in about twenty minutes.
681, message received. Acknowledge content. We have
8:32:50 OP already informed responsible agencies to prepare everything.
Continue with your procedures.
The Captain’s current situation does not look good. The doctor
8:33:02 FA
says it does not look good. We have to land within the
shortest time possible and emergency
equipment must be on
standby to receive him. It’s the only way we can save him…
OK, we have already made all arrangements.
Allow us to ask
8:33:12 OP another question, “is it the FO Li, Shin Tsai, who’s flying the
aircraft?”
8:33:19 FA
Yes, the FO is flying the aircraft. I am not the FO; I’m the
flight attendant.
63

8:33:24 OP Copy.
It’s like this, all you have to do is help me at that aspect.
8:33:28 FO Because you have to monitor my situation. There is a
emergency button down there, if…
8:33:35 FA If I hear him, then I see you operating, right?
8:33:37 FO
If the situation is abnormal, I’m telling to do just two things.
First, to press this button. Just to press this button…
8:33:43 FA What kind of button is this?
8:33:44 FO This is to maintain high altitude
8:33:45 FA Maintain high altitude
8:33:46 FO Right. And then turn the second button to 250.
8:33:49 FA 250, just turn this, right? Turn downwards, but not now.
8:33:53 FO
No w turn from 315 to 250 and make sure that the two lights
are
on.
8:33:57 FA
To ensure the two lights are on, we need to press only one, not
two,
just one.
8:34:01 FO Press it down and it should be okay.
8:34:02 FA Press it down.
8:34:03 FO Just make sure these lights are on.
8:34:04 FA
Ok, these two lights…If altitude is to be maintained, this
is the
switch, right?
And then, all that remains to be done is to get in touch with the
8:34:08 FO
tower following the procedure
we did just now. Get in
touch with the OD. If something happens to me, ask him
for assistance.
8:34:14 FA Ok, ok, ok
8:34:16 FA' How long before you land?
8:34:18 FA About 15 to 20 minutes.
8:34:19 FO About 15 minutes
8:34:22 FO Have we already made the announcement at the back?
8:34:24 FA
I afraid to make the announcement. If the guests knew, I don’t
know how
they will react…
8:34:27 FO Just tell them we’re turning back, that’s it.
8:34:28 WR CI681 descend and maintain FL170
8:34:30 FA Ok, then I will tell them that we’re turning back, ok?
8:34:33 FO Descend and maintain FL170 CI681
8:34:35 FA
The Interphone is there, I’ll use the intercom to tell them we’re
turning back.
8:34:40 FO Let me do the announcement.
8:34:41 FA You’re doing the announcement? Ok!
64

8:34:50 FO
Ladies and gentleman due to aircraft maintenance
problem, we
have to return back to Taipei International Airport. About
landing at CKS
Airport about 15 minutes from now. Sorry for
the inconvenience.
8:35:20 FA It’s closed.
8:35:23 FO This is okay.
8:35:24 FA The light is not on, is it okay?
8:35:28 FO It’s okay, I am going to land right now.
8:35:31 WR CI681 descend and maintain FL150
8:35:35 FO Descend and maintain FL150 CI681
You just monitor
my situation ad the operation of the aircraft
will not be a problem.
After I land, I need you to look at
8:35:47 FO
several things
for me, which I may not look at if I were
communicating with the other party when I land. There
should be two green lights here. If there’s none,
then should
ask me. That’s all.
8:36:12 FA If the two green lights don’t it up, then I should tell you.
8:36:13 FO Right.
8:36:14 FA
There are two green lights, one at each side,
right? At
approximate below how many thousand miles?
8:36:17 FO
No…No…if , after touchdown, you do not see a green light
after 3 to 4 seconds, then shout.
8:36:24 FA
There should
be a green light right after we touchdown. 一
Touch down
8:36:25 FO Just call my name and I’ll know.
8:36:29 FA Then you should have another step.
8:36:30 FO That should be to pull the Reverse lever
8:36:33 FA Reverse, it won’t lit up if you don’t pull it.
Our aircraft is very heavy. I don’t want to use too much
8:36:35 FO runway space. I’ll try to send the Captain home as fst as
possible.
8:36:40 WR CI681 descend and maintain FL150
8:36:44 FO Descend and maintain FL150 CI681
8:36:46 WR
CI681 affirmative and depart B DME fix turn right intercept
ILS runway 06 final approach course
by yourself
8:36:56 FO CI681 confirm can we request 05L
8:36:59 WR Stand by
8:37:11 FO Help me if the marker there is Cat II or not.
8:37:15 FA It’s Cat II.
8:37:16 WR
CI681 depart xerox correction, depart B DME fix intercept
runway 5L localizer over
8:37:25 FO Depart B intercept 5L localizer CI681 thank you
65

8:37:29 WR You’re welcome.
8:37:38 FO Now, please draw the two curtains. Thank you.
8:37:41 FA These two?
8:37:41 WR Break, CI681 contact Taipei Approach 125. 1 see
you
8:37:44 FO It’s up to you, please.
8:37:45 FA No, no, everybody’s in on this.
8:37:51 FO CAL 681, this is Assignment Center over…
8:37:54 FA Assignment Center is calling
8:37:57 FO Assignment Center is calling 681? Why don’t you talk to him?
8:38:00 WR CI681 Taipei
8:38:02 FA CI681, go ahead.
8:38:03 FO CI681go ahead
8:38:03 FO 681 go ahead
8:38:04 WR CI681 contact Taipei Approach 119 ,correction 125.1 over
8:38:10 FA You’re coming through clearly. Plase repeat.
8:38:10 FO 125.1,CI681 good day
8:38:13 WR Good morning
8:38:15 C1 CI681, Taipei
8:38:16 OP The assistant pilot is using Auto landing
8:38:17 FO 681, CI681 with you, passing FL178 for 150.
8:38:23 FA
FO and the officer are now talkikng to each other. Please
repeat.
8:38:23 C1
CI681 Taipei Approach, ident, descend and maintain 11
thousand, Taipei QNH 1013 runway 05L.
8:38:26 OP Please the FO to use Auto Landing.
8:38:31 FO
1013 ,11 thousand, descend 11 thousand, CI681 thank you, say
again wind.
8:38:37 FA
Please repeat now, okay? We were on the line just then and did
not hear what you said.
8:38:38 C1 CI681 now the wind is 070 at 14.
8:38:43 FO Thank you.
8:38:44 FA He wants to talk to you now?
8:38:46 FO OPS, CI681 go ahead
8:38:52 OP They are requesting for Auto land.
Autoland roger. First, let me tell you that according to
8:38:53 FO
procedure, Auto land is not recommend. But as you have made
a request, basically I will monitor you. There shouldn’t be any
problems.
8:39:09 OP
Our department head and chief mechanic hope he can use Auto
land to land the aircraft.
8:39:11 C1 CI681 descend and maintain 4000.
8:39:15 FO
Roger, you tell him
that I’m now overweight. I will implement
Auto land. If things are not normal, I will abort.
66

8:39:19 OP Roger, thank you.
8:39:19 CI681 descend and maintain 4000.
8:39:24 FO Confirm 681 descend to 4000.
8:39:26 C1 CI681 affirmative, descend and maintain 4000.
8:39:30 FO
Descend And Maintain 4000, CI681, and request high speed
below one zero thousand.
8:39:34 C1 CI681 approved as requested.
8:39:37 FO CI681 thank you.
8:39:44 FA Auto land, but we are overweight.
8:39:47 FO These people are…
8:39:48 C1
CI681 depart BRAVO turn right heading 080 intercept
localizer runway 05L.
8:39:54 FO
080 depart from BRAVO intercept localizer runway 5L,
CI681.
8:40:06 FA
Sir, why are you listening to them? If this SOP is not in
accordance…
8:40:11 FO
No, there’s no problem. But this aircraft has to be inspected on
the Ground.
It’sdoesn’t matter.
8:40:19 FA It’s okay, if there is any danger….
8:40:21 FO There is no danger; there is no danger in landing.
8:40:24 FA
Right, if you are sure, if what he just instructed will in any way
put our safety at risk, we’ll just follow SOP!
8:40:31 FO There is no danger.
8:40:32 FA
Because the chief mechanic and the department head are not
AB6 pilots, right?
8:40:47 FO
We can do Auto Land, because I will monitor it. If there is any
problem, I will abort. There are monitor procedures in the Auto
Land. It may be real heavy, so we will ask the ladies to sit tight
and we will secure the Captain.
8:40:55 FA He’ ging to give warning.
It’s like this. I will talk to him first and aks them to sit tight.
8:41:00 FA How long will it take? He said 4000 feet, but he’s still at
11000. Is it correct that he’ll be right here?
8:41:17 FO Yes, yes, we’ll be right be right there, maybe in 6, 7 minutes.
8:42:35 FO 681 establish on localizer runway 5L.
8:42:38 C1
CI681 roger, 25 miles from outer marker, cleared ILS runway
05L approach.
8:42:44 FO Cleared ILS runway 5L approach, CI681.
8:43:17 FO We land in five minutes
8:43:21 FA We land in five minutes.
8:44:16 FA
Don’t be nervous. Sir, go slow, please start from the beginning.
There’s no problem. This is the latest aircraft model.
8:44:29 FO I am more worried about the Captain, not about the aircraft.
8:44:53 677 OPS, 677
67

8:44:55 OP
Officer Chang, Yeh Chia Wei, Officer Wei is coming over.
Please pay attention to the 681 situation.
8:45:04 677 Ok what is his situation?
8:45:05 OP
681, Captain has lost consciousness in-flight. The FO is now
preparing to land.
8:45:11 677 What are you calling me for?
8:45:14 OP Captian Yeh, please monitor CAL 681 situation.
8:45:18 677 I am at the gate. How do I monitor from the gate?
8:45:20 OP
Yes, the call a while ago confirmed it. Please listen
for a
while….if
you need any assistance.
8:45:25 677 Ok, I am now on the Approach frequency.
8:45:54 C1 CI681 contact Taipei Tower 118.7, Good day.
8:45:58 FO 118.7 Good day CI681.
8:46:10 FO Taipei Tower CI681 ILS runway 05L twelve miles.
8:46:17 C2
CI681 Taipei Tower, runway 05L, wind 080 at 17, QNH 1013
cleared to land.
8:46:25 FO
Cleared to land CI681,
runway 5L roger, please say again the
wind.
8:46:29 C2 CI681 surface wind 080 at 17.
8:46:34 FO 080 at 17 CI681
8:46:36 AREA Gears down
8:46:37 FO Plase calla policeman, don’t mind it.
8:46:38 677 Ok, Lin Shin, I’m Chang Chien Ho. Is there any problem?
8:46:42 FO No problem, I am now at ten miles entering ILS.
8:46:46 677 Ok, Auto land in an over weight situation.
8:46:50 FO Roger,Now that the APU has started, follow procedure.
8:46:52 677
Flare is not enough. If it is Flare,
if it is enough, just release to
help it flare a bit.
8:46:57 FO Yes,roger
8:46:58 677 Ok.
8:47:00 FO Why don’t w wait and see?
8:47:06 FA
What are you going to do afterwards? After you release, just
step on the brakes.
8:47:09 FO Yes, I will use automatic brakes.
8:47:12 FA
You’ll be using automatic brakes. If you sense anything wrong,
just use the automatic brakes.
8:47:18 FO Good fellow, sorry, but I can’t talk to you right now.
8:47:43 677 OPS 677
8:47:45 OP Sir, please call the officer.
8:47:46 677
I want to ask if the Captain of 681….Is the medical emergency
equipment ready or not?
8:47:53 OP
It’s all ready….Sir, Mr.
Tung is requesting that you monitor
and assist him….
68

8:47:59 677
Yes, our IP has already communicated with Lin Shin. Now he
is on final descent
at 7, 8 miles. He’s going to land soon. Let’s
wait until he lands, then push back.
8:48:08 OP Roger Roger
8:48:10 677 Currently speaking, there is no problem.
8:48:14 FO Reading out check list
8:48:36 AREA Going through OM
8:48:42 FO OM, 1400 Check
8:48:59 677 Lin Shin, at what distance are you right now?
8:49:02 FO 3.5
Ok pay attention
to the flare on top of FMA. The most
8:49:03 677 important is that
the flare still has thrust retard. If there is no
flare, release immediately and then switch to manual flight.
8:49:04 FO Check
8:49:25 FO Wind check please,
8:49:30 C2 CAL 681, this is Taipei Tower.
8:49:32 FO Please come in.
8:49:33 C2 Is the person you have just spoken with your OD?
8:49:37 FO IP.
8:49:39 C2 How was he able to shoot this wave channel?
8:49:43 FO I don’t know.
8:49:44 FO I don’t hav time to talk now.
8:49:46 C2
Can you notify us? There are other aircrafts under control at
this moment.
8:49:49 FO Roger I am landing now.
8:50:08 AREA Three hundred
8:50:15 AREA Two hundred ( Sound of IM)
8:50:23 AREA One hundred
8:50:28 AREA Fifty
8:50:30 AREA Thirty, fifteen, ten, frive
8:50:37 AREA Sound of
landing
8:50:41 FO Reverse check, manual brake"80"
8:50:49 FO Eighty
8:50:57 FO Fans on ,Sixty ,Idle thrust
8:51:15 AREA Sound of auto pilot disengagement
8:51:18 C2
CI681 high speed
N7 turn off, and cross runway 05R, contact
ground 121.7.
8:51:25 FO
681 roger, we vacate runway on the 23L and stand by for the
tow car.
8:51:32 C2
Ok, CI681 left turn join runway 23L, and hold between N9 and
N7, stand by further.
8:51:56 FO Operation, 681 has landed.
8:51:59 OP Thank you, sir. Congratulations.
69

8:52:01 C2 CI681 contact Taipei Ground 121.7 for further.
8:52:05 FO 121.7 CI681.
8:52:08 FO Ground CI681 holding N7.
8:52:11 C3 CI681 Taipei Ground roger, confirm you want tow car.
8:52:18 FO 681 where is our parking bay?
8:52:21 C3 CI681 confirm you need a tow car to tow you to Bay 608.
8:52:26 FO 608 roger, so we need tow car.
8:52:29 C3 CI681 roger now hold your position.
8:52:34 FO Hold N7, CI681.
8:53:07 FO OPS, CI681
8:53:09 OP 681 go ahead
8:53:11 FO How long will the tow truck take?
8:53:13 OP Immediately, sir. Please standby.
8:53:15 FO Please hurry, our captain is in trouble. Hurry.
8:53:18 OP Copy
8:53:29 C3 CI681 taxi a little bit ahead and hold between N7 and N9.
8:53:36 FO 681 roger
8:53:38 C3 CAL 681 to Taipei Tower
8:53:40 FO Come in.
8:53:52 FO Come in, 681
8:53:54 C3 CAL 681 to Taipei Tower.
8:53:56 FO Come in, 681
8:53:59 C3 CAL 681 to Taipei Tower
8:54:01 FO Come in, CAL 681
8:54:04 C3 Please wait where you are, sir.
8:54:07 FO
Roger that. At the left front side there is a car, which is unable
to taxi.
8:54:10 C3
Roger, you should wait where you are. The firefighting truckis
on the ground right now.
8:54:14 FO Roger.
8:54:21 FO How long do we have to wait for the tow car?
8:55:04 C3 CAL 681 to Taipei tower
8:55:06 FO Come in, 681.
8:55:07 C3
681, please stay where you are and await further instructions.
Now please close the car.
8:55:11 FO Car closing…
8:55:13 FO 681 Roger.。
8:55:37 FO Ops, this is CAL 681
8:55:42 OP Come in, 681
8:55:43 FO How long will the tow car take?
8:55:45 OP
The tow car has already gone out. I don’t know what’s
taking thm this
long. Please standby.
70

8:55:49 FO It’s a matter of life and death.
8:56:13 FO XXXX
8:56:40 FO What aircraft….
8:57:16 FO Operation CI681
8:57:20 OP Go ahead please
8:57:21 FO
Is the tow truck coming or not? If it doesn’t come soon, I will
have to start the engines and taxi.
8:57:25 OP
Can you communicate with tower? We have already notified
the tow car, but it’s taking a long time in coming. If you notify
tower and it agrees, then you can taxi first.
8:57:37 FO
The tow tuckhas already gone to tow the Pax Aircraft away.
The chief pilot has died.
Who is going to take responsibility?
8:57:45 OP Roger roger
8:57:47 FA Tower is allowing you to taxi, just taxi.
8:57:48 FO My engines are closed.
8:57:50 FA
Oh, your engines are closed down. You can’t communicate wit
tower.
8:58:29 FO Ground, this is 681.
8:58:31 C3 Please speak.
Request start engine. We have been waiting too long for the
8:58:33 FO tow truck. Captain may have problems. I want
to request start
engine and do the taxi myself.
8:58:39 C3 Okay, you may drive.
8:58:41 FO Thank you.
8:59:25 C3 CAL 681 to Taipei
8:59:26 FO 681, go ahead
8:59:27 C3 681, please inform us as soon as you are ready to taxi.
8:59:29 FO Roger…two minutes.
9:00:04 FO
I have been wanting to go to the bathroom from the time the
parking bay has not been changed.
9:00:07 AREA (Cockpit interphone call)
9:00:08 FO Answer him…
9:00:11 FA Please speak
9:00:12 FO 681Ready for taxi
9:00:14 C3 681, please taxi with the yellow airline truck in front of you.
9:00:22 C3
681, please wait a while. There are people beneath your
aircraft. We will notify them to leave.
9:00:26 FA There are people beneath the aircraft.
9:00:28 FO
Roger. Oh, the tow car is here. I’ll wait for the tow car. I am
shutting down the engine. Thank
you.
I’ve already told you that the commanding officer has already
9:00:30 FA
called
dozens of times. But company regulations state that FO
is not allowed to taxi. The tow car is here now…the tow car s
here
now.
71

9:01:03 FO GND Cockpit GND Cockpit
9:01:13 GND Cockpit from GND.
9:01:14 FO Go ahead
9:01:15 GND
Pleas throw the Gear Pin down from the window. We need to
plug in the Gear Pin so we can tow the aircraft.
9:01:20 FO Do you not have a Bypass Pain?
9:01:22 GND Bypass pin has
already plugged in.
9:01:24 FO Why do we need the gear pin?
It’s airport regulations. The gear pin of the landing gear must
9:01:26 GND
be plugged in so the aircraft can be towed.
9:01:31 FO I’m only one person here. How can I leave my seat?
9:01:35 GND Okay. Wait a minute.
9:01:38 FO Parking brake, Do we release it or not?
9:01:41 GND Not yet…not now. The tow truck hasn’t come yet.
9:01:47 FO Regulation….regulations, xxxx!Still more regulations.
9:01:59 FO Is he comin up? Is he coming up from below?
9:02:19 FO He should be able to push it open. Help him open it, okay?
Plase open it up so our personnel can go up and get theGear
9:02:22 GND
pin.
9:02:28 FO Do not stepon it…Do not step on the cover.
9:02:37 FO Ground cockpit
9:02:39 GND Please speak.
9:02:40 FO I’msorry for the bad attitude, but the Captain….
9:02:45 GND We know…we know….
9:02:49 FO Just cover it.
9:03:11 FO
We need the tow truck now…The foot ramp should not be
stepped on.
9:03:17 FA What about his brakes?
9:03:25 FA This is important.
9:03:26 FO We don’t have it yet, wait for him.
9:03:27 FA Wait for him to call out.
9:03:28 FO Standby for the parking brake
9:03:32 GND Cockpit from ground
9:03:33 FO Go ahead
9:03:34 GND Sir, please loosen the brakes.
9:03:37 FO Brakes loosened, please start towing, thank you.
9:03:39 GND Towing…
9:03:43 FA Please speak (facing the back)
The commanding officer has already called for it many times,
but there are company rules. The company does not allow it
9:03:48 FA to wait by the taxi. We have already contacted the tow truck;
it will be there shortly. Just bear with it, okay? We have
already called them lots of times.
72

9:04:27 FO Operation CAL 681
9:04:33 FO Operation CAL 681
9:04:35 OP Go ahead 681
9:04:37 FO
Is the ramp car on stand by at the parking bay? The Captain
has already lost too much time. Please, it has to be on stand by.
9:04:44 OP Copy
9:04:45 FO Thank you.
9:05:40 End of recorder
73

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74

附錄二 中正塔台地面席/ 消防車 / 中正航務組指
揮 /救護車無線電(頻 道 459.2MHz)通訊紀錄抄本
I HEREBY CERTIFY THAT THE FOLLOWING IS A TRUE TRANSCRIPTION
O F THE RECORDED CONVERSATIONS PERTAINING TO
THE REPORTED
CASE. Name:林怡忠
Title:塔台長
中正塔台地面席 /消防車 /中正航務組指揮/救護車無線電(頻道 459.2MHz)通訊紀
錄抄本
TRANSCRIPT OF
COMMUNICATION BETWEEN Taipei TWR
Ground Control/ Fire truck/ FOC/
Ambulance, on May 8, 2000 on CH
One (459.2).
UTC Com. Contents
003200 救護 車 消防隊,救護車呼叫。
消防隊 救護車請你不要呼叫,請你在原地待命。
FOC 航務一號,…呼叫。
FOC 1 航務一號回答。
003212 他在 6 號跑道。
是的,謝謝。
003217 消防車 塔台,南站消防車脫離 24。
塔台 Roger。
塔台,請問一下,在 SP 上的 EVA 的飛機要拖
??
到哪裡?
他待會兒要拖到 B5,現在讓他到 S6 上稍待可
塔台 以嗎?
S6 上稍待是嗎?
塔台 會不會影響到你們?
塔台 SP 上的長榮拖車,塔台。
長榮拖車 長榮拖車回答, 請講。
塔台 你現在左 轉加入 S6,在 SS 外稍待。
長榮拖車 長榮拖車瞭解,謝謝。
北站消防車直 接切入這個接駁機坪,我們走接
003318 消防車 駁機坪裡面。
消防車 北站消防車收到。
003450 FOC103 塔台,黃 車 103 呼叫,Over。
FOC103 塔台,黃車 103 呼叫,Over。
003505 塔台 請稍待。
103 位置在 W 交通道,請求經 W、SP 到 S1
003510 FOC103 Stand by, over。
003517 塔台 黃車 101,可以通行。
75

FOC103 103 可以通行。
塔台,北 站消防車已到達 608 待命,請問回航
003523 消防車 航機還多久可 以落地?
塔台 目前還沒有消息。
消防車 Roger。
003535 塔台 預計是 45 分。
塔台 預計落地時間是 45 分。
黃車 103 塔台,黃車 103 已到 S1 Stand by,over。
塔台 稍待。
消防二號 救護車,消防二號。
救護車 請講。
003740 消防二號 請你到消防車一號旁邊來。
003745 塔台 OK,航務組消防車跟黃車 103,塔台。
黃車 103 回答,請講。
塔台,黃車 103 回答,請講。
003802 塔台
中華 681 現在請求用 5 左落地,用 5 左落地,請
你們移防到北邊來。
Roger,103 由 SC、W 到 5 左跑道,over。
塔台 Roger,可以走 SC、W 進入 NP 前呼叫。
Roger,NP 前呼叫。
003832 ??? N10 北面消防 車 到 N6 待命。
塔台廣播,消防車你們可以走滑行道,然後自
003840 塔台 行避讓航機。
消防車 Roger 請求進入 E。
塔台 可以的。
003903 消防一號 塔台,消防一號呼叫。
塔台 請講。
消防一號 位置 608,請求進入 SS、W 到 N6 待命。
塔台 可以的。
003937 到 N10 待命。
Roger。
003942 消防 108 消防 108 航務組。
航務組 108 回答。
003948 航務組
你有沒有帶手機,能夠 , 可以的話,打個電話
到航 務 組 來給我。
消防 108 Roger。
004002 黃車 103 塔台,黃車 103,預計到達 NP 前,Over。
塔台,黃車 103,是否可以繼續由 NP 到 N1
004018 黃車 103 Stand by, over。
004030 黃車 105 103,105 現在在國內機坪待命。
黃車 103 Roger。
76

004048 消防車
塔台,消防車位置 在 W 前,請求由 NP 前往 N6
待命。
塔台 可以到 N6。
004058 消防車 收到,可以到 N6。
004110 黃車 101 塔台,黃車 101 呼叫。
塔台 101 呼叫塔台嗎?
101 現在位置在 E Cross 跟 NP 交口,我們請求
004117 黃車 101 進入副跑道。
塔台 103 對不對?
004125 黃車 101 黃車 101。
塔台 101 可以進入副跑道。
塔台麻煩可不 可以告訴我們一下,681 預計甚麼
004135 黃車 101 時候可以落地。
塔台 現在螢幕上看不到。
黃車 101 請你有進一步消息,麻煩廣播。
004145 塔台 OK,中華 681 預計 在 7 分鐘後落地。
黃車 101 Roger,在 7 分鐘後落地。
004158 消防車 塔台,北 站消防車已到 N6 待命。
塔台 Roger。
004205 消防車 塔台,南站消防車到達 N10 待命。
塔台 Roger。
塔台 ,黃車 103 請求由 NP 到 N6 Stand by,
004228 黃車 103 over。
塔台 103 可以的。
黃車 103 Roger 103。
004306 黃車 105 103,105 呼叫。
黃車 103 103 回答請 講。
004312 黃車 105 等一下航機落地 ,我就直接 Follow 飛機了。
黃車 103 Roger。
004324 塔台 塔台廣播,中華 681 在五邊 25 浬 。
消防車 消防車 Roger。
004550 黃車 103 105,黃車呼叫 103,over。
黃車 105 105 回答。
它待會脫離跑道後,我 follow 他到接駁機坪,
004555 黃車 103 over。
黃車 105 Roger,跑道上面交給我。
黃車 103 Roger。
塔台廣播,五號跑道五邊要落地的就是中華
004628 塔台 681。
消防一號 消防一號 Roger。
004642 黃車 105 塔台,105 現在在國內線機坪,681 落地後我直
77

接進入 follow。
塔台 105,Roger。
黃車 105 謝謝!
004845 黃車 101 塔台,黃車 101 呼叫。
塔台 101 請講。
004854 黃車 101 請問五邊落地的飛機,是不 是中華 681?
塔台 對的,現在要落地的就是中華 681。
黃車 101 101,Roger。
004906 黃車 103 塔台,黃車 103 呼叫,Over。
塔台 103 請講。
請問落地 681 有沒 有預計由那一個滑行道脫
黃車 103 離,over。
塔台 我沒辦法預測,看他自己的落地情況。
黃車 103 oh,over。
004923 中華拖車 塔台你好,中華拖車。
塔台 中華拖車,請講。
中華拖車 中華 605 在維護區 拖往 A4 號,請放行。
塔台 稍待。
中華拖車 Roger,在維護區稍待。
005015 消防一號 塔台,消防一號呼叫。
塔台 消防一號,請講。
塔台
….
落地以後你們可以自行進入跑道。
消防車 Roger,謝謝。
塔台 飛機落地後,你們 可以自行進入跑道。
消防車不要進入跑道,走副跑道就可以了,速
005122 航務員 度放慢。
消防車 消防車知 道。
005134 中華拖車 塔台,中華拖車呼叫。
塔台 拖車,有飛機要走 E,請稍待。
中華拖車 好,謝謝。
005152 消防車 南站消防車跟塔台呼叫,現在歸隊。
塔台 南站消防車 Roger。
005200 消防車 塔台,南站消防車現在脫離 N10。
塔台 Roger。
005206 消防車 北站消防車除 救護車外,都可以呼叫歸隊。
塔台 北站消防車知道。
005253 黃車 101 塔台,黃車 101 呼叫。
塔台 101 請講。
現在 681 停在副跑道上,現在下一步準備怎麼
黃車 101 樣?
78

005300 塔台 他要找拖車拖行,他不自己滑,要找拖車拖。
黃車 101 101roger。
005310 塔台 所有消防車都可 以撤離了,謝謝。
消防一號 消防一號,roger,謝 謝。
005318 救護車 塔台,請問一下需不 需要救護車?
塔台 救護車現在先稍待一下。
救護車 救護車我建議你還是 跟著飛機好了。
005335 消防車 塔台,北站消防車呼叫。
塔台 北站,請講。
005340 消防車 北站消 防車請求 N7 回北機坪。
塔台 Roger,可以的。
005355 消防車 北站消防車注意,現在飛機滑行。
005410 黃車 105 塔台,105 脫離五左跑道,Runway clear。
塔台 Roger,謝謝。
005416 消防車 塔台,南站消防車請求穿越 24 跑道至南消。
塔台 你可以過 24。
消防車 謝謝,可以過。
005434 黃車 101,這個中華要用拖車拖嗎?
塔台 中華拖車,OK,可以拖行,E 交通道前呼叫。
中華拖車 中華拖車,可以拖行,北消前呼叫,謝謝。
005455 中華 681 是不是要用拖車拖回來?
塔台 對的。
拖車要用拖桿,請你準備拖桿,通知可以到副
黃車 101 跑道上。
好!好!知道。
塔台,北站消防車脫離北邊跑道,進入北 消,
005508 消防車 謝謝。
塔台 Roger。
005514 消防車 塔台,南站消防車脫離 24,謝謝。
中華兩號拖車 塔台,中華兩號拖車呼叫 。
005522 塔台 中華兩號拖車,請講。
飛機貨機 617 在 Cargo511,拖回中華維護區,
請放行。
005538 Cargo511 的現在可以後推。
005548 黃車 101 桃勤拖車,航 務組黃車 101 呼叫。
桃勤拖車 桃勤拖車。
黃車 101 請問你們拖車位置在那裡?
桃勤拖車 我們現在準備拖,還沒有。
005612 黃車 101 請儘快過來,請儘快, 謝謝。
005704 塔台 Cargo511 的,你要拖到甚麼位置?
Cargo511 的要拖回中華維護區。
79

005711 塔台
Roger,後推完 成之後,往前拖,暫時不要進入
E。
Roger,謝謝。
005818 塔台 黃車 101,塔台。
黃車 101 黃車 101,回答。
塔台 黃車 101,塔台。
005849 塔台 黃車 101,塔台。
黃車 101 塔台,黃車 101 回答。
中華 OD 通知,中華 681 請他再開車,自行滑到
005854 塔台 608。
黃車 101 Roger。
005904 黃車 101 我們引導他到 608,謝謝。
OK,我請他自行開車,然後,開車完畢就用滑
005911 塔台 行的。
黃車 101 現在 E 上面這個,他是不是要走 E 過去。
005918 塔台 那我可以安排。
黃車 101 Roger。
黃車 101,我們請飛機跟著你,走副跑道、E 到
005940 塔台 608。
黃車 101 101,Roger。
010025 塔台 黃車 101,塔台。
塔台 黃車 101,塔台。
010039 黃車 101 101 回答。
塔台 黃車 101,塔台。
黃車 101 塔台,黃車 101 回答。
010046 塔台 現在拖車又過去了,可能又要變更了。
黃車 101 101roger,101 還是在副 跑道等待。
010051 塔台 Roger。
塔台,黃車 101 現在脫離副跑道,回到北機
010245 黃車 101 坪,脫離波長,謝 謝。
塔台 101,Roger,謝謝。
010388 桃勤 拖車 塔台,桃勤 拖車。
塔台 桃勤拖車,請講。
現在副跑道的拖車,現在準備好了,是不是可
桃勤拖車 以開始拖。
010345 塔台 好,你走副跑道,然後 ECHO 到南邊。
桃勤拖車 好,知道。
011054 塔台,CI681 是不是繼續拖到 608。
塔台 CI681 走 SP 到 608。
Roger,知道,SP 到 608,謝謝。
011122 塔台 桃勤拖車 CI681,塔台。
80

桃勤拖車 聽到,請講。
你在 S6 前面稍待,國泰進來,他第一架飛機進
塔台 來。
桃勤拖車 好、好,知道,國泰離開後,我們再到 608。
011136 塔台 對。
011224 塔台 CI681 拖車直接走 SP 到 608。
(註:此時桃勤拖車在 ECHO 滑行道上,塔台
指示拖車在 S6 前稍待,係為航管隔離之預防措
施,桃勤拖車前進過程塔台未曾延誤。)
011600 黃車 105 航務組,105 呼叫,over。
航務組 請講。
黃車 105 請一位教官送照相機到 608。
航務組 608….嗎?
011620 黃車 105 對,照相機。
012005 桃勤小客車 塔台,桃勤小客車呼叫。
塔台 桃勤小客車,塔台,請講。
桃勤小客車
桃勤小客車現在在 NP 交通道,W 前,等待許可
進入 W 到 608 受傷區去工作。
012023 塔台 桃勤小客車可以通行。
桃勤小客車 可以通行,桃勤小客車,Roger,謝謝。
012032 塔台 你要走那裡?
桃勤小客車 我到南面交通道。
塔台 桃勤小客車,roger。
012128 桃勤小客車 塔台,桃勤小客車,脫離 W,謝謝,再見。
塔台 桃勤小客車,roger,再見。
013012 航務組 航務一號,航務組。
013020 航務組 航務一號,航務組。
013132 航務組 航務一號,航務組。
013135 航務組 航務一號,航務組。
013144 航務一號 航務一號回答。
(註:由上述時間至 0140 時均無有關 CI681 之
通話。)
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82

Appendix 3 Transcript of Communication
BetweenCAL 681/Taipei Approach/Taipei
Tower/Taipei Ground on Frequnecy
125.1/118 .7/121.9 MHz
I HEREBY CERTIFY THAT THE
FOLLOWING IS A TRUE TRANSCRIPTION
OF THE RECORDED CONVERSATIONS
PERTAINING TO THE REPORTED
CASE.
Name:Lin, Yi-
Ch ung
Title:Tower
Co ntrol
TRANSCRIPT OF COMMUNICATION BETWEEN CI681/ Taipei Approach/ Taipei Tower/ Ta ipei Ground on M ay 8, 2000 on FREQUENCY 125.1/ 118.7/
121.9
P:Pilot of CI681
C1: Controller of Taipei
Approach
C 2 : Controller of T aipei Tower
C 3 : Controller of Tap ei Ground
UTC Com. Contents
003815 C1 CI681, Taipei
P 681,CI681 with yo u,
passing FL178 for 150.
003822 C1
CI681 Taipei Approach roger, ident, descend and
maintain 11000, Taipei QNH 1013 Runway 05L.
1013 11000, DESCEND 11000,CI681 thank
003830 P
you,say again wind.
C1 CI681
now the wind is070 at 14.
P Thank you.
003910 C1 CI681 descend
and maintain 4000.
C1 CI681 descend and maintain 4000.
P Confirm 681 descend to 4000.
C1 CI681 affirmative, descend and maintain 4000.
P
Descend and maintain 4000, CI681, AND request
high speed below 10000.
003934 C1 CI681 approved as requested.
P CI681 thank you.
83

003946 C1
CI681 depart BRAVO turn right heading 080
intercept locaizer runway 05L.
080 depart from BRAVO intercept localizer
P
runway 5L,CI681.
004235 P 681 establish on localizer runway 5L.
C1
CI681 roger, 25 miles from outer marker, cleared
ILS runway 05L approach.
P Cleared ILS runway 5L approach, CI681.
004554 C1 CI681 contact Taipei Tower 118.7, good day.
P 118.7 good day CI681.
P Taipei Tower CI681 ILS runway 05L twelve miles.
004612
004644
CI681 Taipei Tower, runway 05L, wind
080 at 17,
C2
QNH 1013 cleared to land.
Cleared to land CI681, runway 5L roger, please say
P
again the wind.
C2 CI681 surface wind 080 at 17.
P 080 at 17 CI681.
和哥…你好,有沒有問題,沒問題吧!
P
沒問題,我現在十 浬進場 ILS。
和哥 overload, overweight
的情況之下,就是
flare 會比較不夠,如果認為 flare 如果不夠的
話,就是 release 把他調整一下。
P Roger.
OK.
004859 你現在幾浬?
P 3.5。
OK,注意上面的 floor,……Floor release,然後
flap….
004930 C2 中華 681,這是台 北塔台。
P 請講。
C2 剛才跟你通話的是不是你們的 OD?
P IP.
004939 C2 請問他怎麼發射這個波道的?
P 我不曉得。
如果要使用麻煩通 知我們一下,還有其他飛機
004945 C2
在管制當中。
P Roger we are landing now.
C2 Roger.
005118 C2
P
CI681 highspeed N7 turn off, and cross runway
05R, contact ground 121.7.
681 roger, we vacate runway on the 23L and stand
by for the tow car.
84

005130 C2
OK, CI681
left turn join runway 23L, and hold
between N9 and N7, stand by further.
005205 C2 CI681 contact Taipei Ground 121.7 for further.
P 121.7 CI681.
005209 P Ground CI681 Holding N7.
CI681 Taipei Ground roger, confirm you want tow
C3
car.
P 681 where is our parking bay?
CI681 confirm you need a tow car to tow you to
005219 C3
Bay 608.
P 608 roger, so we need tow car.
C3 CI681 roger now hold your position.
P Hold N7, CI681.
CI681 taxi a little bit ahead and hold between N7
005328 C3
and N9.
C3 中華 681,台北。
005354 C3 中華 681,台北。
C3 中華 681,台北。
P 中華 681 請講。
005403 C3 教官請你原地稍待。
P 瞭解,左前方一台車不能滑行。
對的,你要在原地稍待一下。現在地面消防車
C3
在通行。
P Roger.
005502 C3 中華 681,台北。
P 681 請講。
005508 C3 681 你留在原地稍待,現在請你關車。
P 681Roger.
005830 P 地面中華 681。
C3 請講。
Request start engine,等太久了,Captain 可能會
005833 P
有問題,Request start engine,自己滑。
005841 C3 好的,可以自己開車。
P 謝謝。
005924 C3 中華 681 台北。
P 681 請講。
C3 681 準備好滑行通知一下。
P Roger 好的。
010012 P CI681 ready for taxi.
681 你跟前方航務黃車,跟他滑,預計走
C3
ECHO。
010034 C3 681 等一下,你飛機下面有人,我們通知他們離
85

開。
P 靠上來了,我檢查一下 shutdown engine。
86

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87

Appendix 4 Transcript of Inteprhone
Communication of Taipei Tower
I HEREBY CERTIFY THAT THE
FOLLOWING IS A TRUE TRANSCRIPTION
O F THE RECORDED CONVERSATIONS
PERTAINING TO THE
REPORTED
CASE. Name:Lin, Yi-
Chung
Title:Tower
Contro l
TRANSCRIPT OF COMMUNICATION BETWEEN Taipei
TWR/ Interphone on
May 8, 2000 on Telephone NO. 3983023 & 87702192
UTC Com.
Contents
005440 TWR
….
Tower.
Tower, we have a question. Does Cal 681 need a
FOS
tow car or not?
TWR Yes, it needs a tow car.
Please ask him to stay where the aircraft is right
FOS
now and turn off the engines.
TWR Okay.
Please ask him to stay where the aircraft is right
FOS
now
and turn off the engines.
TWR Turn off the engines?
FOS Turn off the engines, turn off the engines.
TWR OK, OK.
….
005758 TWR This is TWR.
Hello, this is the operation center. Cal 681 would
like to taxi by himself, because the tow car has
not
arrived yet. The Captain has already lost
CAL OD consciousness and is in danger.
The tow car has not come. Does he want to
TWR
taxionhis own?
CAL OD Yes, that is right.
TWR Does the pilot know?
CAL OD The pilot knows. He has already asks us.
TWR Okay, okay.
….
88

005827 APP
STANDARD
Hello.
TEAM Hello, I’m Lin Ro-Chun.
APP Hello.
We have not been able to get in touch with the
Sung Shan Tower. That means that we do not
know if the China Airline flight from Ho Chi
STANDARD Minh City has already entered the Gate. If it
TEAM hasn’t, we hope it doesn’t taxi.
APP
STANDARD
I don’t know, please wait.
TEAM Okay.
….
TWR
STANDARD
Please go on.
TEAM Hello, is this Tower?
TWR
STANDARD
Yes.
TEAM Hello, please wait a minute.
TWR Hello.
STANDARD Hello, I am the POI of China Airlines. If he lands,
TEAM
where is he going to land?
He’s going to land at the secondary runway and
then rendezvous
at the meeting point of N7 and
TWR the secondary
runway.
STANDARD Okay, okay, then have it stop there Is everything
TEAM
being implemented now?
Well, you have
a person, who is asking your pilot
to taxi, which
means the tow car does not have
TWR
to be used. Is it the case?
No, he does not have…he is now…I think the
pilot…. Ask him to assign tow car…Ask him to
park at the secondary runway, where he will not
STANDARD be in anyone’s way….and then have the tow car
TEAM tow it away….because…
TWR He is now in the way…he is now in the way…
STANDARD Why don’t we ask him to taxi ahead a little bit
TEAM
tow here he will not be in anyone’s way, okay?
TWR You are asking him to taxi, is that it?
STANDARD Not to taxi by himself… ask him to use the
TEAM aircraft…the tow car.
No, no, another person from your end asked him
to taxi on his own, that you will not assign any
TWR
STANDARD
tow car anymore.
TEAM Which person?
TWR Another person from your end?
89

STANDARD
TEAM I am not China Airlines. I am form the FAA.
TWR Oh, the FAA, excuse us.
STANDARD I do not recommend that he taxi, because the co-
TEAM pilot has not undergone training for taxiing.
But their own pilot, in that condition…. Who is
TWR
STANDARD
this?
TEAM I’m Fan…Fan Hong Chi.
TWR Oh, from what team are you?
STANDARD I am the CAL POI officer in charge of airline
TEAM safety.
Oh! But he said it was his Asian Dispatch Center
representative who said….Oh! Now the tow car is
also already here. You say that now they want to
TWR
STANDARD
have the aircraft towed?
TEAM Right, right.
TWR
STANDARD
Please wait a moment.
TEAM I’ll call them via phone…
The tow car is already on its way. They should be
TWR
STANDARD
able to use the tow car to tow the plane away.
TEAM Okay, okay.
TWR
STANDARD
OK。
TEAM Thank you.
0010050 TWR Not at all.
….
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91

Appendix 5 Transcript of Interphone
Communication Between Taipei Area Control
Center/Taipei Approach/Taipei Tower/CKS Airport
Flight Operation Section
I HEREBY CERTIFY THAT THE FOLLOWING IS A TRUE TRANSCRIPTION
OF THE RECORDED CONVERSATIONS PERTAINING TO THE REPORTED
CASE.
Name:Lin, Yi-
Chung
Title:Tower
Control
TRANSCRIPT OF INTERPHONE COMMUNICATION BETWEEN Taipei Area
Control Center (TACC) /Taipei Approach (Approach) /Taipei Tower (Tower) /CKS
Airport Flight Operation Section (FOS) on May 8, 2000
UTC Com. Contents
Tower, CI681 is coming back immediately due to
illness of one of its passengers. It needs an
001748 TACC
ambulance.
001756 Tower An ambulance? Okay, thank you.
001800 TACC Not at all.
001803 Tower Do you know that CAL 681 is coming back?
Approach No, we don’t.
Okay. I’m telling you now. There is a sick
Tower passenger on the aircraft. This is the reason.
Approach Okay. CAL 681, roger that. Thank you.
001821 FOS FOS…
001823 Tower CAL 681 is coming back, I repeat, coming back.
FOS CAL 681 is coming back.
The reason is because there is a sick passenger on
Tower
the aircraft.
FOS There is a sick passenger.
Tower They need an ambulance.
FOS Okay.
Tower We are not yet certain of the time, please standby.
FOS Okay! Okay!
002030 Approach Sir, where is CAL 681 going to stop?
Tower We’re still making arrangements.
Approach Uh?
92

Tower
We’re still making arrangements Still making
arrangements.
Approach Where is it coming back from? Where is it going?
Tower CAL 681…
Approach Is it Hong Kong or somewhere else…
Tower Look at your takeoff records.
Approach Okay, I’ll look for it.
002339 FOS When it comes back, it should land at 608.
Tower Okay, thank you.
002510 FOS He lost consciousness.
Tower Please.
Hello, the Captain has lost consciousness, so the
FOS
firefighting truck will have to mobilize.
Tower What? The captain of 681 has lost consciousness,
FOS It’s true, so the firefighting truck has to mobilize.
Tower Roger, we understand.
002555 Approach Please.
CAL 681 has notified FOS that it is the Captain
Tower who has lost consciousness.
Approach What?
Tower We are calling the firefighting truck.
Approach Okay.
Firefighting truck, when the aircraft lands, please
Tower close off the runway temporarily.
Approach Roger.
002653 Tower Roger.
Approach Hello。
681, please communicate with the radar man,
Tower he’s….
Approach Radar man already knows.
Tower Please note what the co-pilot has to say.
Okay, we will ask the SP to talk to the OD. We will
Approach
give a permit for direct entry.
Tower Right, right, just allow him to have a smooth entry.
002805 Tower Hello。
FOS May we ask how long until they land?
Bravo estimates 38 minutes, 45 minutes more or
Tower less.
FOS 45 minutes before landing, okay, thank you.
Please notify firefighting team. Or do we notify
Tower them?
Well, why don’t you notify them? You should
FOS
appraise them of the situation.
Tower Okay, thank you.
93

003255 Tower Please.
CAL 681, please turn back. He needs an
TACC ambulance; you know that!
Tower Roger.
TACC OK.
003313 FOS FOS…
Reconfirming, CAL 681, does he need an
ambulance?
Yes, we need an ambulance.
I was, I followed that….ahead of me.
Roger, I’ll get in touch again with the ambulance.
Thank you, Bye-bye。
Shio Shio, You are at D Man. Does the problem of
CAL 681 lie with the aircraft or with a passenger of
002550
the aircraft?
We have been in touch with the tower. He needs an
ambulance.
We now know that the Captain has lost
consciousness. Who said that? The Tower has been
in touch. The Captain has lost consciousness. Let
me call the CAL Airport Services Center. Let me
002620
us; we will give them direct entry, ok?
003230 Western side, come in.
CAL 681 has applied for First Priority. He said that
the patient is in critical condition. I have voided the
speed limit of ATA.
OK.
I am southern side. I’ll direct him towards the
003405
nearest way.
CAL 681, you are flying direct TIA.
I gave him the nearest route. What do we do
afterwards?
Okay, no problems. Afterwards, I shall suggest
borrowing airspace with Taichung. Then going to
a lower altitude, and then fly straight-in. We’ll
work it out form here to make for early landing.
I’m asking you if he will have a problem flying
straight TIA.
I don’t have a problem here, because he is Number
One Priority。
CAL 681 shall go to ILS 5left runway after
003625
BRAVO FIX. Is this alright?
No. 6, No.6.
Is he No. 6?
Yes.
003710 CAL 681, please ask for Left 5.
94

Okay, we will reposition the firefighting truck.
95

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96

附錄六 EEG Report
97

附錄七 Flight Personnel Physical Examination
Standards
100

101

102

103

104

105

106

附錄八 Civil Aviation Personnel Physical
Examination Handbook
107

108

109

110

111

112

Appendix 9 Confirmation Report on the Cause of Death
113

114

115

116

117

Appendix 10 Drug Confirmation Report
118

119

120

121

122

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123

Appendix 11 Cover Page of the FAA Physical
Examination Form
124

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125

Appendix 12 Emergency response Plan of ICAO
Airport Services Handbook Chapter 4.2 on
Accidents Occurring In and Out of the Airport
4.2.1 General Principle
場站外失事機場緊急應變計劃及相互支援協議應一併實施,各單
位作業行動詳見 4.2.2-4.2.11。
4.2.2 Initial Notification
場站外失事應為目擊證人提供給警察消防隊或地方警告簽派中心
(Alarm and Dispatch Centre)該中心基於緊急狀況特性通報給適
當單位。
4.2.3 Mobilization of Aviation Services
4.2.3.1 使用圖 8-2 之警告通訊系統進行初使通告。
4.2.3.2 提供有管轄權的緊急應變單位,失事位置、參考方格
圖、其他基本資料,包含失事時間及失事時間、航機機
型,隨後視可能再提供乘客數、燃油量、駕駛員及機載
危險物品數量位置等。
4.2.3.3 依據機場應變計劃通知警備、航站管理、醫療服務單
位,提供方格參考資訊。
4.2.3.4 視需要發佈 NOTAM 內容為:
”Airport rescue and Fire fighting service protection
unavailable until ( Time ) or until further notice. All
equipment committed to aircraft accident.”
4.2.3.5 複查檢查表中上述應進行的行動,寫下完成通告時間、
簽名。
4.2.4 Mobilization of Airport Firefighting and Rescue Personnel
4.2.4.1 場站外失事正常應由航管單位、地方警察、消防隊通知航
站消救單位,根據相互支援協議應有受指定之消救車輛
應趕赴現場。
4.2.4.2 航站消救單位應
(a) 前往由地方警察協調適當之出入道路到達失事現
場。
(b) 與相互支援消救單位進行協調。
(c) 赴現場途中與具管轄權之消救單位交換下列資訊:
(1) 等待點及運作區
126

(2) 人力及裝備狀況
(3) 其它確定資訊
4.2.4.3 航站消防資深人員應向有管轄權之地方消防隊資深人員
報告並請求指示。
4.2.4.4 先前簽訂之協議應由航站消防單位及場外支援單位簽訂
包含航廈及棚廠應有消防裝備,牽涉航廈之消防應由何
單位指揮等。
4.2.5 Mobilization of Police Services
4.2.5.1 第一位抵達的機場警備,有責任與現場指揮官協調並負警
備職責,需建立緊急車輛出入口道路之通暢,直到指定
之警察單位到達。
4.2.5.2 警備單位主要責任為交通順暢及現場警衛。應通知適當之
聯絡中心可抵達現場之出入路線。與現場指揮官聯繫後
進行出入路線之交通管制輔助緊急應變車輛。
4.2.5.3 警衛及警察須處理失事現場週邊交通,避免破壞散落現場
之物品。
4.2.5.4 失事現場須設警戒標誌隔離入侵、媒體、旁觀者、打劫
者。建立警告標誌警告侵入現場人員將可能受到重大傷
害,接近失事現場 100 公尺處嚴禁煙火。
4.2.5.5 聯絡介於所有警備點、指揮所及緊急操作中心應立即完成
通連。
4.2.5.6 圖 8-2 顯示應立即通知人員。
4.2.5.7 警備單位或或授權單位應訂定背章、現場通行證及識別卡
的樣式。
4.2.5.8 特別提供飛航資料記錄器及座艙語音記錄器的保護、增加
信件保護、保管危險物品及保護人員防止爆炸及放射物
傷害。
4.2.6 Mobilization of Airport Management
相互支援協議規定航站管理應採取下列行動:
(a) 到達失事現場
(b) 若須要時啟動航站緊急應變中心及行動指揮所
(c) 應具管轄權之指揮要求擴大支援
(d) 通知航空公司
(e) Notify the other agencies 通知圖 8-2 之其它單位
(f) Provide medical equipment and personnel
4.2.7 Mobilization of Medical Services
4.2.7.1 民防及地方應組織醫療服務,航站之醫護中心也應參
與。
127

4.2.7.2 依據與航站週邊單位訂定之相互支援協議航站醫療應提
供部份醫療用品、設備及人員至失事現場。
4.2.8 Hospital Mobilization
4.2.8.1 Provide medical services
4.2.8.2 Confirm that when emergency incidents happen, doctors,
nurses, operating room, counseling units, surgery, blood
bag preparation.
4.2.9 Mobilization of Airline Company
4.2.9.1 航空公司資深代表須報告予現場行動指揮官協調航空公
司作業狀況,若失事航空公司非機場使用者,機場管理
者應指定場內適當航空公司處理,直到該航空公司人員
到達。
4.2.9.2 航空公司資深代表應提供機載乘客名單、飛航組員及危
險物品放置位置,危險品包含易爆物、壓縮、液態氣
體、易燃液固體、氧氣瓶、有毒物質、傳染、放射物
質,並將該危險品資料之告知消防指揮及醫療協調者。
4.2.9.3 安排交通工具運送未受傷乘客指定的未受傷人員休息
區,禁止可行走之受傷乘客之運送,除非獲得醫護協調
者允許。
4.2.9.4 航空公司人員應前往未受傷人員休息區,由資深人員負
責指派該公司人員負責接待、登記及福利工作。
4.2.9.5 航空公司在未受傷區的代表,須觀察乘客須要適時提供
額外的醫療服務、衣物、電話設備等服務。
4.2.9.6 接待人員須在乘客由失事現場前往休息區之下車處等
候,指引乘客登記處位置,這些人員應了解廁所、電
話、衣物、飲食位置。
4.2.9.7 登記人員應於手冊中記錄乘客姓名,意欲如何安排行
程,如旅館安排轉機或其他運輸工具,登記人員須列出
乘客身體及心理或潛在狀況,之後給與乘客一個身份標
籤(如附錄七第十段),登記後指示該乘客到福利協調
者處。
4.2.9.8 Representative from the airline company should be
responsible for communicating the incident to the following
agencies:
a) Health and social welfare agencies (Department of
Health and Department of Social Welfare)
b) Bureau of Customs
c) Bureau of Entry and Exit
128

d) Post Office
e) Environmental Protection Agency
4.2.9.9 Senior airline officials have the responsibility of contacting
next of kin.
4.2.9.10 The airline company, in cooperation with the PR of the
airport and other agencies, should make a formal
announcement.
4.2.9.11 The airline company is responsible for removing the aircraft’s
wreckage from the scene, with permission from the agency investigation the incident.
Please refer to Airport Service Manual(Doc9137),Part5-Removal of Disable
Aircraft
129

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130

附錄十三 Emergency response Plan of the
ICAO Airport Services Handbook Chapter 12 on
Communication 國際民航組織機場服務手冊緊急
應變計畫第十二章通訊
12.1General Principle
All personnel involved in the incident should established two-way
communication, including off-site support groups. This is to enable the site
commander and emergency center to continue to be able to maintain communication
links with all the units involved. At the same time, back-up communication channels
should be planned for in the counterplan.
12.2 Communication network
12.2.1 Where there is more than one agency involved in the rescue effort,
communication links are of major importance.
12.2.2 There should be an adequate number of direct link radios,
telephones, and other communication equipment establishing
primary and secondary communication channels. This
communication network should link the emergency center, site
commander as well as all the agencies involved.
12.2.3 Direct communication methods should be provided to the following
agencies:
a) Between tower or aviation services team, airport management
personnel, airport machine operators, or airline company and
airport emergency rescue unit.
b) Between tower and aviation services team, fire
station/firefighting assignment center and firefighting and
rescue personnel on the road and on the site.
c) Off-site support units, which include the police notifying al
possible support groups.
12.3 Communication equipment
d) Between firefighting vehicles, firefighters should have a
way of communicating with each other.
131

12.3.1 Adequate number of communication equipment should be provided
make sure that personnel involved are able to act on situations. The
following equipment should be provided:
12.3.2 Wireless radios: portable two-way radios should be provided to every
unit involved in order to be able to communicate with the site
commander.
12.3.3 Communication regulations should be strictly controlled to make sure
that lines are not busy. Each unit should use a different channel; a
channel should especially be reserved for the site commander.
12.3.4 The radio channel used by the site commander should enable him to
directly link up with the aircraft and ground control personnel. He
should also be equipped with earphones to minimize interference.
12.3.5 To communicate directly with the cockpit, Cockpit to Ground lines
may be used. 須要配套之連接器、線材、麥克風及耳機,因此須航
站消救人員及航空公司相互配合。
12.3.6 行動指揮所需具備足量電話及行動電話線路與場外單位通聯以減
少無線電頻率通話負載過重。
12.3.7 醫療單位及救護車須要通訊能力利用週遭醫療機構之先進生命支
援系統。
12.3.8 行動指揮所須裝備通訊規劃良好之車輛及通訊操作人員。
12.3.9 需記錄緊急應變中心或行動指揮所含時間的所有通聯狀況。
12.3.10 Other communication equipment like should be considered 其他通訊
裝備之考量如擴音器。
12.4 場坪及候機室意外
12.4.1 航站管理或航空公司應建立發生在候機或機坪意外之通訊系統,
以利快速反應(機坪意外包含客艙失火,燃油外洩,航車碰撞,
緊急醫療)。
12.4.2 機坪主管應配置雙向直通中央控制室之通訊設備。
12.4.3 航機謝載區或空橋(loading gate or jet way)須有電話裝設於登機口
及機坪層,緊急電話號碼須明示在電話機上。
12.5 Testing and Inspection
12.5.1 Communication system should be tested on a daily basis (including
wireless radios and telephone communication network).
12.5.2 A complete list of the telephones of units and personnel should be
provided to every participant of the emergency procedures and should
be updated monthly.
132

Appendix 14 Emergency response Plan of the
ICAO Airport Services Handbook Chapter 9 on
Categorization and Examination of Injuries and
Medical Care
9.1 Immediate care of injured persons from the aviation incident
Many people die because injuries sustained from the incident do not receive
immediate medical attention. It is necessary for the medical agency involved to
respond timely and categorize these injuries so that appropriate medical measures
may be applied.
9.2 Categorization of Injuries (Applicable to all emergency situations)
The priority by which categorized injuries are dealt with and govern post-
incident care are as follows:
9.2.1 The injured may be divided into four levels:
1 st level: Immediate care
2 nd level: Delay care
3 rd level: Minor care
4 th level: Deceased
9.2.2 The first qualified medical personnel to reach the site should proceed
with categorization of injuries until a senior individual or the flight
surgeon arrives at the scene. The victims should be transferred from
the injury categorization area to the appropriate care area. The victims
should also wait until injuries have stabilized before being moved to
the designated hospital.
9.2.3 The victims belonging to the first level of injuries should be given
priority treatment and sent to designated hospitals ASAP. This is the
responsibility of the personnel categorizing the injuries.
9.2.4 The categorization of injuries completed on site is most effective. The
only thing is that the people on the site should send the victims to the
hospitals as soon as possible or remove them from the site. As a
principle, moving the victims should not interfere with emergency
firefighting work.
9.2.5 Categorization of injuries should make use of identification cards to
help in the arrangement for transport to the hospitals.
133

9.3 Standardization of Injury Identification cards and their uses
9.3.1 Color and identifying marks shall be used to distinguish the cards from one
another. This may improved the care given to the victims as well as shorten
the length of time before the victims are sent to the hospitals.
9.3.2 The identification card should be water proof and protected from the
elements of the weather:
1 st level or immediate care: red, roman numeral I, and the mark of a
rabbit.
2 nd level or delay care: yellow, Roman numeral II, and the mark of a
turtle.
3 rd level or slightly injured: green, Roman numeral III, and the
ambulance has an X mark.
4 th level or casualty: black
9.3.3 If there are no identification cards, Roman numerals may be written on
tapes or directly on the forehead or skin of the injured to signify priority
level or how to deal with the person. If there are no markers, lip balms may
also be used.
9.4 Principles of Care
9.4.1 Patients whose conditions are serious need ot be stabilized on site and then
transported to the hospital within the shortest time possible.
9.4.2 Firefighters or the first batch of personnel on the scene should understand
that people in serious conditions needs to be stabilized first. Other situation
such as the control or prevention of fire should not be the primary focus.
Firefighting personnel should listen to the instructions from personnel
trained in first aid. The first ambulance to arrive at the scene should have
equipment for dealing with injuries, such as : trachea tube, bandages,
oxygen tanks, and others to stabilize the conditions of the patients with
external injuries as well as to provide rescuers with adequate oxygen.
Particular attention must be given to risks posed by clothing, which have
flammable oil as other flammable liquids, which may come in contact with
the oxygen.
9.4.3 To stabilize the conditions the first few minutes before more professional
people arrive to deal with them or until the special external injury team
arrives, where they can proceed with more complicated procedures like
CPR.
9.4.4 The categorization of injuries, as well as supplementary emergency methods,
must be implemented by a medical coordinator. However, prior to the
134

arrival of the medical coordinator, this responsibility rests on the director
othe rescue operations.
9.4.5 The medical coordinator should to notify the site director about all the
medical rescue situations. The most important job of the medical
coordinator is that of management; he or she should not participate in giving
medical assistance.
9.4.6 The medical coordinator should wear a white hat, with the words Medical
Coordinator written in the front and back of a white jacket, for easier
recognition.
9.4.7 Injuries categorized as 1 st level injuries include:
a) Brain hemorrhage;
b) Severe smoke inhalation;
c) Asphyxiating thoracic and cervico- maxillo- facial injuries;
d) Cranial traumata with coma and rapidly progressive shock;
e) Compound fracture;
f) Extensive burns exceeding 30% of skin surface;
g) Crush injuries;
h) Other types of shock;
i) Spinal cord injuries.
9.4.8 Methods of care include:
a) Emergency rescue
b) Maintian consciousness
c) Give oxygen
d) Place in tent awaiting transport to hospital
9.4.9 Injuries categorized as 2 nd level injuries include:
a) Non-asphyxiating thoracic and cervico-maxillo-facial injuries
b) Closed fractures
c) Limited burns less than 30% of skin surface
d) External skull injuries not causing a loss of consciousness or
shock
e) Injury to the soft parts of the body
9.4.10 Victims with injuries belonging to this category are not on the priority
list for transport to hospital.
9.4.11 Injuries belonging to the 3 rd level are considered light injuries. They may
interfere with the implementation of priority medical treatment.
Consequently, the main hing to do is to transport such patients to the
designated waiting area.
135

9.4.12 The airline company or the Red Cross should provide care to those with 3 rd
level injuries as well as to designate a waiting area beforehand. They may
use an empty hangar, the firefighting station, or an area within the airport.
There should be provisions for ventilation, lighting, water, telephone,
bathroom, and other facilities. This position should be made known to all
airline company personnel as well as all airport tenants.
9.5 Control of flow of the injured victims
9.5.1 Four care areas should be established as in Fig. 9-1
a) Assembly area-The seriously injured should be housed in this
area where the paramedics will turn them over to medical
personnel.
b) Injury categorization area- should be at least 90m from the site
and may be put up in different areas.
c) Care area-After categorization, the injured shall be placed in
respective care areas, which will be divided into three levels:
1 st level: Shall be identified via a red banner or stremer.
2 nd level: Shall be identified via a yellw banner or streamer.
3 rd level: Shall be identified via a green banner.
d) Transportation area- Shall be placed between the exit and care
areas. There shall only be one transportation area or else a
communication network should be put up.
136

Fig. 9-1 Flow chart of categorization of injuries as well as medical care
9.5.2 Mobilization equipment is of help in stabilizing the conditions of victims
with 1 st and 2 nd level injuries. Lengt ofuse does not exceed 30 minutes.
a) Simplified or recovery ambulances shall be used by victims
having 1 st level injuries. Recovery ambulances are able to
transport the victims to the hospitals.
b) The red tent, designated for the seriously injured, will be equipped
with ventilation and lighting facilities which will be brought iver
together with all the required medical equipment.
c) The yellow tent is designated for victims in the 2 nd level.
137

138

Appendix 15 Flight Safety Report During the
Course of the Accident Investigation
No.: ASC-IFSB-89-05-01
Incident: On May 8, 2000, China Airlines Flight 681 returns to Chiang
Kai Shek International Airport due to incapacitation of the chief
pilot, where medical personnel proceed to board the aircraft and
administer emergency procedures.
Date of Report: May 19, 2000
Report Items:
1. On the matter of the co-pilot discovering the captain’s incapacitation
when the aircraft was flying on an altitude of 31,000 feet,
preliminary investigation showed that after landing, the medical
personnel was not able to board the aircraft immediately and
administer emergency medical procedures.
2. To prevent any similar delays, the board makes the following
recommendations:
a. When aviation personnel has an emergency situation on hand, he
should use the standard emergency phraseology MAY DAY,
MAY DAY or PAN, PAN to relay the seriousness of the current
situation to the responsible persons.
b. Upon receiving of notification of such emergency situation, each
department at the airport as well as the airline company should
actively communicate with each other and exchange information.
Moreover, as soon as the aircraft lands, these departments should
implement the most effective method as well as assign medical
personnel to administer real time medical assistance.
Jieh Kai
Executive Director
Aviation Instrument Aviation Flight Safety Board
139

Appendix 16 Amended Recommendations on the
Report of the Ministry of Transportation and
Communication Civil Aviation Association
140

141

Appendix 17 China Airlines’ Amended Report and
Recommendations
142

143

Appendix 19 Airport Operations
156

157

158

159

160

161

162

163

164

165

166

167

168

169

170

171

National Library Published Material Editorial Information
Investigation report on a serious incident involving a China
Airlines airplane (B-18503,A300-600R), while flying from Chiang
Kai Shek International Airport to Ho Chi Min City, Vietnam, pilot
became incapacitated
Edited by Aviation Safety Council
ISBN 957-02-7893-5 (Paperback)
1. Aviation Serious Incident Investigation
2. Flight Safety Council
557.909 90002100
Investigation Report
A Serious Incident Involving a
China Airlines B-18503, A300-600R Aircraft , while flying
from Chiang Kai Shek International Airport to Ho Chi Minh
City, Vietnam, the pilot became incapacitated during flight.
Editor: Aviation Safety Council, Executive Yuan
Publishing Agency: Aviation Safety Council, Executive Yuan
Tel. No.: (02) 25475200
Address: 16th floor., No.99, Fu Hsing North Road, Sung Shan District, Taipei City
Website: http://asc.gov.tw
Publishing Date: January 2001

ASC-AIR-00-12-002
ISBN: 957-02-7893-5
Aviation Safety Council
16 th Floor Fu-Hsing North Road
Taipei 105,Taiwan, R.O.C.
Tel: 886-2-2547-5200
Fax: 886-2-2547-4975
URL: www.asc.gov.tw
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